| | Integrator Forum: 7 Voices on Whether the Bravewell's | |
Summary: No one doubts whether the Bravewell Collaborative's new mapping study added useful understanding of the nation's health system-sponsored and academiac health center-sponsored integrative clinics. But do these thumbnails, reports and tables on these 29 clinics capture what the title suggests: Integrative Medicine in America: How Integrative Medicine is Being Practiced in the United States? I posed the question. Here are responses from: public health acupuncturist and researcher Beth Sommers, MPH, LAc, PhD; holistic medical doctor Bill Manahan, MD; Integrator columnist Michael Levin; rehab specialist and past American Association of Medical Acupuncturists board member Mitchell Prywess, MD; an anonymous integrative MD; National University of Health Sciences president Jim Winterstein, DC; and senior editor of the Textbook of Functional Medicine Sheila Quinn. i conclude with my own speculations on what might be different in community-based integrative medicine.
The mapping study on the state of integrative medicine funded and carried out through the Bravewell Collaborative of philanthropists is a remarkable contribution to our knowledge of integrative clinical centers sponsored by health systems and in conventional academic medical settings. I posted my first take in the Huffington Post: New Bravewell Report a Goldmine for Those Intrigued by Integrative Medicine, Pandora's Box to Skeptics.
However, I was nagged by a question that I noted in the first piece: Does the report, widely covered in the media, misrepresent the whole field as its sweeping title suggests: Integrative Medicine in America: How Integrative Medicine is Being Practiced in the United States? The survey looked at just 29 health system-sponsored, and often medical school-sponsored centers. What of the literally thousands of other clinics and centers delivering "integrative medicine" of some kind? Thus this Integrator Forum: Does the
Landmark Report "Integrative Medicine in America" Actually Portray Integrative
Medicine in America? The query provoked a half-dozen responses. Here they are. I add some comments along the way and a table of my own quesses at the end.
 Beth Sommers, LAc
Elizabeth Sommers, PhD, MPH, LAc is a founder and current director
of research and education
for Boston-based Pathways
to Wellness/ AIDS Care Project. The tremendous contributions of Pathways were featured in the February 2012 Integrator Round-up. Sommers is the co-chair of the Alternative & Complementary Health Practice Primary Interest Group of the American Public Health Association.
"Thanks so much for publishing the Bravewell Collaborative's report "Integrative
Medicine in America". This represents an important first-step in identifying best
practices and demonstrating the array and diversity of integrative approaches.
"At the Institute of Medicine conference in 2009 (‘Integrative Medicine and the
Health of the Public'), there was a lively debate about how these practices
should be described. ‘Integrative health' can be inclusive of a spectrum of
practices - some of which are modalities administered by trained, licensed
providers, and others which are self-help activities that might include
lifestyle factors involving nutrition, exercise or stress reduction.
"Although the jury is still out regarding what to formally call this collection
of practices, as a public health advocate I prefer to use the term ‘integrative
health'. This nomenclature allows us to explore a larger slice of activities
that include community-based practices that may occur outside the realm of
academic medical centers. One example of this might be the National Acupuncture
Detoxification Association, which has created hundreds of centers world-wide that
address issues of recovery from chemical dependency. These services occur on
reservations, community health centers, mental health facilities, homeless
shelters, military veterans' clinics, and prisons. Another pivotal sector to
poll includes nurses who've incorporated a variety of therapeutic approaches
into their scope of practice.
"For the next stage of a report on integrative health in America, I'd like to
see a broader and more representative slice of integrative practices. As you
suggest, polling practitioners of integrative modalities would be one way to
address this. There are also many hospitals across the country that offer
access to some of these practices, but do not formally consider themselves as
providers of integrated care.
"Appreciating the spectrum of integrative approaches amplifies our understanding
of health and, more importantly, puts the emphasis on education and
self-empowerment for consumers."
Comment: My bias is with Sommers that since the prize in this "paradigm" shift from reactive disease management is less medicine and more health, our words should guide us an "integrative health" rule our words. But as my marketing colleague Ruth Westreich likes to say, the naming of "integrative medicine" is already a fact, whether we like it or not. So there are two questions here: What is "integrative practice in America"? Then there is the more narrow question: What is "integrative medicine in America" if we define that by those all those choosing to use the medicine term, rather than what one or another of us unilaterally decide is in the study set.
 Mitchell Prywess, MD
Mitchell Prywess, MD, FAAPMR, FAAMA, DAAPM is a physical medicine and rehabilitation specialist and medical acupuncturist who is a graduate of the Fellowship in Integrative Medicine at the University of Arizona. He is a part board member of the American Academy of Medical Acupuncture. Prywess practices out of The Center for Pain Rehabilitation in Danbury, Connecticut.
"Great
question, John. The report & your inquiry are both timely.
"As one of the 800 AZCIM graduates, who practiced a form of
Integrative Medicine for nearly two decades with no additional Integrative
Medicine credentialing (other than eventual Medical Acupuncture certification
in 2000), I am invited to address a group of Naturopathic Medicine students at
the University of Bridgeport to discuss Integrative Medicine and share my own
personal insights.
"Am I not preaching to the choir, in this regard?
"It would appear to me that as more traditional Western trained
physicians come on board to lay claim to the practice of Integrative Medicine (popularized by Dr. Andrew Weil), we will need to explore how this
burgeoning field within academic medical centers and health systems integrates
well with those community-based practitioners. My hope is that rather than a 'turf battle' that can potentially isolate practitioners (i.e.,
Medical Acupuncture vs. the majority of acupuncturists, who are non-MDs), we
find a way to work together so that everyone benefits, especially the patients
we serve.
"Having said that, I am a long time supporter of Bravewell's
efforts, and very pleased that this report was published. It certainly offers
the majority of allopathic physicians, who have no idea of what Integrative Medicine
is about, a lens into the future direction of Medicine & healthcare that
they need to learn more about."
Comment: Simmering above and around the question raised by the report is the 'turf battle' to which Prywess alludes. The comfort of this subset of integrative medicine centers being presented as the whole ball of wax feels uncomfortably like the top-down medicine of old. It's not factually correct. I am reminded of how medical doctors use "physician" to refer only to
their guild, denying that chiropractors and naturopathic doctors are each, according to the US Department of Labor, also physicians. (I do
realize that using "allopathic physician," as Prywess does, is problematic, especially for
an integrative MD whose philosophy and approach do not fully reflect what
Hahnemann meant to describe with that term.)
Meantime, my close colleagues in the Consortium of Academic Health Centers for Integrative Medicine (CAHCIM) - and some of very good friends and close colleagues are in this organization - refer to CAHCIM as "The Consortium." They do this even when in direct dialogue with members of the Academic Consortium for Complementary and Alternative Health Care (ACCAHC). The latter however becomes the "CAM Consortium." The unspoken assumption is that the dominant player needs no modifier. Yet the "conventional Consortium" allows room for others, as does "allopathic physician." A good way to lay Prywess course away from the turf battles is to not lay claim, with our language, to turf that is not one's own.
 Michael Levin
Integrator adviser and columnist Michael Levin has served in executive capacities for both conventional pharma and natural products firms. His passions in integrative care focus on cost issues, incentivizing wellness, and product quality. He presently consult with a variety of entities.
"Thanks
for surfacing Bravewell's exceptionally well-crafted and sorely needed report.
Great stuff!
"Does
this report actually portray integrative medicine in America? No, this
simply does not broadly represent 'Integrative Medicine in America'
but rather a very important segment of integrative medicine in America. To
their credit, the authors acknowledged the limitations in scope, which may be
more accurately defined as: 'Integrative Medicine as Practiced
in 29 Conventional-Medicine Centric Health Systems.'
"And
that's perfectly OK. Unlike 'Integrative Medicine in America', this
disciplined subset is far more amenable to research and quantification. Thanks
to Bravewell's great work, we now have a current, data-driven view into
one important corner of the 'amorphous Integrative Medicine
breadbox.' Measurement is the first step in the march towards best
practices."
Comment: I feel like Scrooge McDuck running my hands through the gold in this report. If you haven't opened it, click in and enjoy. Credit the Bravewell for giving us this baseline for health system integrative medicine centers in 2011-2012.
4. Anonymous Integrative MD: "Don't be expecting Bravewell funding ..."
An integrative medicine colleague who knows that under another of my hats I am involved in seeking philanthropic support for ACCAHC chided me in an email: "I guess you aren't expecting support from the Bravewell anytime soon."
Comment: It's true, I don't expect money from the Bravewell. This is not because of this column, however. Rather, Bravewell has made it clear that as a group they only fund projects led by medical doctors. The agency I work for is not. They do what they want, of course. I would hope that we are all big enough to realize that one can both celebrate the good that an organization does (as I do in my two prior pieces, and here) and also offer criticism. Monoculture weakens the genes, doesn't it?
 Bill Manahan, mD
Integrator adviser Bill Manahan, MD is a long-time leader of holistic and integrative medicine who has also maintained a continuous role as clinical faculty at the University of Minnesota School of Medicine.
"Your question is: Does this portrait capture what a
consumer is likely to experience - or what you as an integrative medicine
practitioner offer? Is the field appropriately
represented here? Does the report misrepresent? What would be different if such
a report were based on surveys of community-based practices?
"My answer is that the portrait does represent how integrative medicine is
being practiced in MEDICAL CENTERS and HOSPITALS across the
U.S. So, if we interpret the words in the article's title - Clinical Centers - as
Medical Centers, then the report does what its title claims it does, and,
therefore, does not misrepresent.
"But, no, the Bravewell Report does NOT represent how
integrative medicine is being practiced in thousands of medical offices around
the U.S. There is a completely different world of integrative
medical care being practiced in private offices, and most of those physicians
are not connected to a medical center or hospital. What those physicians
do in their practices goes well beyond what is occurring in most of the
practices described in the Bravewell Report.
"It would be wonderful if Bravewell would now write a new report based on a
survey of physicians practicing in private practices. They could easily
get a list of those physicians by going to the American Association
of Naturopathic Physicians, American Holistic Medical Association, American
College for Advancement in Medicine, American Academy of Environmental
Medicine, American Academy of Anti-Aging Medicine, Institute of Functional Medicine,
Age Management Medicine Group, and a few others. The portrait of those
practices would be different from much of what is described in this Bravewell
Report.
"In 2010, I visited 25 such practices, and my findings were published as a guest
editorial in Explore:
The Journal of Science and Healing, July/August 2011, Vol 7, No 4,
pages 212-214, titled, "The Whole Systems Medicine of Tomorrow: A
Half-Century Perspective." There was an art and a science practiced
in those integrative medicine clinical settings that embodied the best of
allopathic medicine practices and added the multiple elements of
integrative holistic medicine that significantly raised the bar regarding
patient satisfaction and outcomes. It was a powerful and moving experience
for me to observe the various physicians practicing medicine in a manner that I
am quite sure will someday in the future be considered normal and
routine. And, interestingly, the physicians satisfaction rate regarding
enjoyment of their practices was an astounding 4.4 on a scale of 1 to 5.
They loved what they were doing, and so also did their patients. I
discovered that there is a way for physicians to have fun practicing outpatient
medicine and at the same time help people achieve health and healing."
Comment: Manahan comes close to answering the question I posed. He states that "what those physicians
do in their practices [out in the community] goes well beyond what is occurring in most of the
practices described in the Bravewell Report." But how? With what therapies or approaches or providers? I would guess that the community practices do go beyond these. But in other ways, I'd expect that we'd find they are less likely to use certain modalities and approaches that are in these health system center - some case to the detriment of their patients. See my own postulates at the end of this series of comments.
6. Bill Manahan, MD #2: "In states where NDs have prescription authority, they are ideal practitioners of integrative medicine"
I followed up Manahans submission with a pointed question: "What do YOU think of naturopathic doctors (NDs) with broad pharmacy authority and right to
manage patients as 'integrative medicine'?" Manahan responded:
"It seems logical to me that in those states where the ND's have some
pharmaceutical prescribing ability, they are the ideal integrative
practitioners doing integrative medicine. Their basic training for four
years is primarily integrative medicine. Those of us trained in
allopathic medicine have the majority of our training in acute care
medicine, and then we have had to learn integrative medicine along the way
during our years of practice. Sometimes that works and sometimes it is
probably not the best way to learn. Admittedly, we are now beginning
to have some good training programs for MD's and DO's in integrative
medicine so that is good.
"I do think that the ND's would benefit (and enjoy it) by requiring a two-year
residency after their four years of ND school. One year would be
with an MD or DO in a primary care office and the other year would be with an
ND in his or her office practice.
"At the same time, what I envision for many primary care practices are
small clinics in which MD's and DO's work side-by-side with ND's so each of
them can do what they are trained to do best."
Side-note: There is a great deal of work going on in the naturopathic profession to expand residency opportunities. To understand the NDs challenge, medical doctors need to imagine what sorts of residency opportunities MDs would have if Medicare did not subsidize residencies to the tune of billions as Medicare presently does. Big challenge. When will Manahan be appointed to fill the CMS vacancy Don Berwick left?
 Jim Winterstein, DC
Jim Winterstein, DC has over 40 years in the chiropractic field. He is president of National University of Health Sciences where he personally has a practice right that includes acupuncture and his program in chiropractic medicine educates a broad scope chiropractor. He is a regular Integrator commentator.
"It was an interesting
read, but so what? Conspicuous by their absence (mentioned but not in the main
roles) are naturopathic and chiropractic physicians.
"The most frequently employed (full or part-time)
practitioners at the integrative medicine centers in the study are physicians,
followed by acupuncturists, massage therapists, meditation instructors,
dieticians/nutritionists, and yoga instructors."
"The Bravewell Organization has fallen
into the same tired litany so often used by the allopathic profession. 'Physicians' are ONLY those with the MD or DO credential and ALL
others are simply one kind of 'technician or another.' Well, its nice
that 'physicians' have granted these 'technicians' some
role in 'integrative care,' but for me, at least, the reality is no
different than it was when I was an x-ray tech in the sixties. Decision makers
are MDs and all others 'do as they are told.' It would be my
guess that NONE of these 'technicians' would even be in the picture,
and, in fact, there would be no 'integrative medicine' at all, if it
were not for the public pressure of the past decade or so, and to a degree,
even that seems to be waning.
"I think it is telling, however that
once more allopathy has managed to simply usurp the 'tools' of some
of what they would call 'allied health technicians' and use them to
buttress their own fortifications (allopathic temples of 'healing'
called hospitals), while keeping complete control of patient care. Its ironic
that oriental medicine is an entire system of healing with a complexity that
rivals anything about Western allopathy and it has been around for several
thousand years and yet, allopathy has such a grip on our society that it can
simply relegate it to the position of 'technician.'
"The report is interesting, but that's
about all as far as I am concerned."
Comment: Winterstein's words seethe with the turf wars to which Prywess alludes. His employment of the "technician" term does not, to my reading, come from language in the report. Where I feel the term is right is in the objectifying term that integrative MDs often use in referring to chiropractors and other practitioners: modalities. Winterstein is right about the inappropriately limited use of "physician," as I note in my comment to Prywess. Yet I have the disquieting sense that Winterstein's history is not allowing him to see change where it does exist. We need to remain open, on all parts. For medical doctors, this means openness to letting go of sole rights to "physician" and to "integrative medicine." For some chiropractic doctors, it means allowing medical doctors to disgorge the opposition to nature in their allopathic training.
8. Sheila Quinn: "What's missing are evolving mechanisms and tools for treating the cause ..."
Sheila Quinn has been involved in the movement for integrative care since 1978. Her work has included labor as co-founder of Bastyr University, past-chair of the Integrated Healthcare Policy Consortium and past senior editor at the Institute for Functional Medicine (IFM). She currently works as a freelance writer and editor. Quinn wrote: "I wrote a short piece on the Bravewell report for IFM; it's
now posted on their website at https://www.functionalmedicine.org/home/FocusOn/.
I mentioned your article about it and put in a link to The Integrator."
Comment: Quinn's IFM piece focuses on the dearth of outcomes being analyzed in these 29 health system sponsored clinics. Despite their relative bandwidth, the analyses of patient experience are not emerging. While Quinn does not focus on how these clinics may differ from communikty-based functional medicine practices, she cites the definition of "integrative medicine" in the Bravewell study then adds:
"All of this is important and, happily, functional medicine already
encompasses these values and goals. What’s missing from the definition,
however—and what functional medicine offers to all practitioners,
regardless of discipline—is continually evolving mechanisms and tools
for seeking the cause of disease and dysfunction and for individualizing
care. Using a systems biology approach, the functional medicine matrix
and associated tools make it possible to implement integrative medicine
strategies in a systematic, consistent, and effective manner. Without
those elements, it will be very difficult to 'help people regain and
maintain optimum health.'"
Overall comment: These responses have richness in them. But they barely get into the question that Manahan teases and that was front and center for me what I posed the question: What is really different in the patient's experience and the practitioner's delivery in the community-based practices as compared to these clinics that are imbedded in these delivery systems? Here are some of my thoughts about what a comparative study would find.
Guesses on What a Comparative Survey Comparing Community
Integrative Medicine Practices with Academic Health Center IM Would Find
Go beyond the 29 Centers (more)
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More limited than 29 Centers (less)
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- Chelation therapy
- More referral to providers outside the clinic
- Prolotherapy
- More expansive pharmacy
- Moxibustion and cupping
- More energy healing
- More primary care
- More perception of success with asthma,
ADHD, immune disorders
- More relatively obscure lab tests
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- Less formal employment of health coaches
- Fewer types of practitioners on site
- Less formal lifestyle change programs
- Fewer formal mind-body program services (MBSR)
- Less consultative services
- Fewer onsite psychologists
- Less use of EMR/EHR
- Fewer support groups
- Less massage
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What do you think? We don't know. Sommers says in her comment that a "next stage" of examination and reporting would be fascinating. How would my postulates hold up? Yours?
Yet my guess is that funding such a study is not likely to make the to-do list of the Bravewell Collaborative. Nor does such basic documenting seem to be making the list of fundable projects with NIH NCCAM. Bravewell's strategic focus is on this imbedded set of clinics.
The inequality of access to study funds however reminds me of a familiar truism. We say that what will dominate the understanding that those in the future will have of this time is the "winner's history." It is the winner's story that gets cold. In this portrayal of integrative medicine, it might be said that those whose story is written are, simply, what exists. They the winners.
In March 2012, to writers, researchers, academics and members of the public who are exploring the web, integrative medicine in America is Integrative Medicine in America.
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