Policy

• Washington State pushes to double Medicaid home births: disruptive innovation of the first order

• New SAMHSA addictions guidelines includes CAM
• Holistic Primary Care convenes e-forum of holistic practitioners on the ACA’s individual mandate
• Alyssa Wostrel named executive director of the Integrated Healthcare Policy Consortium

Insurance

• Duke integrative medicine moves to insurance model
• 
  Portland, Oregon’s managed CAM business announces high patient satisfaction, suggestions of cost savings

Academics

• Anne Nedrow, MD to leave Oregon Health Sciences to launch primary care program at Duke Integrative Medicine
• Team care, interprofessional education and the move to give medical schools ownership of collaboration
• National College of Natural Medicine reports the institution’s $56-million contribution to Portland, Oregon economy

• Frank Vitale’s frank explanation of Tai Sophia’s transition from the “academic wellness institute” toward university
• Horse needling: LSU veterinarian school goes integrative

• New York Chiropractic Colleges announces the Veteran’s Administration’s first chiropractic clinical residency

Natural Products

• Proctor & Gamble buys herb company New Chapter

Integrative Care

• Article suggests “integrative oncology” is often non-integrated, parallel practice
• The (intense) home birth midwifery model of integration with other CAM fields 
• Mayo Clinic takes alternative medicine to Mall of America
• Canadian College of Naturopathic Medicine opens oncology research center
• Bravewell Collaborative makes November 2011 symposium talks available
• University of Toronto awards spine professorship to chiropractor
• Acupuncture association reaches out to secure more submissions to their professional journal
• Short Notes on integrative care in the nation’s hospital and health systems

Media

• Can community hospitals learn integration from the military?
• Wallstreet Journal boosts massage as medicine and as stress reduction

Policy

Home birth midwives: Triple Aim threat

Washington State pushes to double Medicaid home births: disruptive innovation of the first order

“Midwives have a central focus in our strategic plan. We are hoping
Washington State can double out-of-facility births in the next two or
three years.” The speaker was Jeff Thompson, M.D., MPH, chief medical officer of
the state of Washington’s Medicaid program. He spoke in a taped
interview for Symposium 2012 — Certified Professional Midwives and Midwifery Educators: Contributing to a New Era in Maternity Care. Thompson proceeded to layout how his state has determined that home birth essentially meets the Triple Aim
evidence Trifecta of satisfaction, effectiveness and cost savings. In his state, Medicaid
payments to licensed midwives for uncomplicated vaginal birth runs
$2,500. Payment for birth center births is $5,000 and doubles again to
$10,000 for those performed inside of hospitals. The cost doesn’t touch
additional savings from reducing the rate of often over-used medical
interventions such as epidurals and inductions of labor. And there’s the rub. An obstetrician presenter noted that the #1 surgery performed in hospitals is C-section, the #1
one diagnostic-related group (DRG) in hospitals nationally is birth and that the #2 two surgery in hospitals is hysterectomy, often associated with
birth. He summed up: “Birth keeps the lights on in
hospitals.”

Comment: See this this Huffington Post article for more. I contributed after attending the Symposium. The posting had generated over 630 Facebook shares, 2,200 “likes” and some 90 comments as of April 3. (See the comment stream.) Can we have true healthcare reform without moving birth out of the hospital and back into our communities – either in birth centers or homes, where normal birth belongs? What could be more radical, or positively disruptive of the present harmful economic preference of US healthcare for hospital services? 

Agency guideline includes CAM

New SAMHSA addictions guidelines includes CAM

A March 12, 2012 press release from Portland, Oregon-based CHP Group reports
that complementary and alternative medicine (CAM) is included in a new
evidence-based clinical guideline that was recently released by the
Substance Abuse and Mental Health Services Administration (SAMHSA).
SAMHSA is part of the US Department of Health and Human Services. The
guidelines is entitled “Managing Chronic Pain in Adults With or in
Recovery from
Substance Use Disorders.” It is published as Treatment Improvement Protocol (TIP) Series
54. HHS Publication No. (SMA) 12-4671. The guideline focused on people with chronic
pain and a history of substance abuse.

The CHP Group, which provides managed CAM services to employers, insurers and managed care organizations (see Insurance,
this Round-up), was connected to the study via CHP co-founder and
medical director Chuck Simpson, DC, a TIP panel member. The CHP release
notes that many patients look for non-drug, non-surgical treatments offered by
licensed CAM providers: “The evidence shows how often these treatments
are sought out and used. One study revealed that over 40% of pain
patients treated with opioids also used some form of CAM. (Fleming S,
Rabago DP, Mundt MP, et al. CAM therapies among primary care patients
using opioid therapy. BMC Complement Altern Med 2007;7:15.)”

Chuck Simpson, DC: on the SAMHSA panel

Comments from SAMHSA consensus panel member Chuck Simpson, DC, vice president and medical director of CHP Group: I asked Simpson for his view of the place of CAM in the guideline. He wrote:

“That CAM was considered at all is a step
forward [in my humble opinion]. The consensus panel was not particularly
CAM-savvy, or CAM advocates. So the
discussions centered around the reality of CAM use in chronic pain
populations
(it’s very prevalent) and the evidence for CAM in chronic pain (it’s
thin) but
conventional medicine approaches to chronic pain and this population in
particular are similarly shy on evidence of effectiveness. And the
evidence of
the down-sides to Rx pain treatment in this population is robust
(e.g  drug diversion, non-compliance, addiction, lack of efficacy). 

“I think that point was made. I was drafted for the
consensus panel because of my publication in an issue of PMR Clinics of North America a
couple of years ago.  It was a great experience. While not
related it’s interesting to see that NCCAM has increasingly focused on
pain and CAM. Will this TIP revolutionize treatment of chronic pain in
people with substance abuse issues?  Not sure.  But it is a small
step.  At this point in my path along CAM integration, I’ll appreciate any
step in the right direction”.

Goldman: HPC forum on the ACA

Holistic Primary Care convenes e-forum of holistic practitioners on the ACA’s individual mandate

During the week of the Supreme Court hearings on the constitutionality of the Affordable Care Act (ACA), Erik Goldman, editor of Holistic Primary Care, queried a few hundred of his mainly MD/DO subscribers for their perspectives as holistic practitioners on the individual mandate in the ACA. Some are compiled here at Practitioners Sound off on Healthcare Reform Hearings. Goldman summarizes that, while most see a need for fundamental healthcare reform: “It seems the holistic community has little love for the ACA or the
individual mandate. Many respondents say the plan fails to address the
main drivers of the country’s health crisis, and does little to foster a
meaningful shift toward holistic care. Further, since many practice
outside of insurance, they are leery of any reform plan that keeps
insurance companies in the Catbird seat.” Goldman reports that 90% of respondents (total respondents not noted) believe the act would be declared unconstitutional. In a March 30, 2012 call for additional perspectives, he summarized themes in early returns as:

• A mandate forcing people to purchase insurance is morally wrong and economically questionable.
• Being against the ACA is not synonymous with being against health care reform.
• Elimination of 3rd party payors and restoration of direct relationships
  between patients and practitioners is the true corrective for the
  system.
• Holistic & integrative modalities have tremendous
  potential for cost savings and for improving health outcomes—if only
  they were given a fair chance.
• Partisan politics & the
  influence of corporate special interests have corrupted the process,
  making meaningful large-scale reform difficult if not impossible.

To participate, email Holistic Primary Care at:

Opinion@holisticprimarycare.net and share what you think about the individual mandate.

Comment: The holistic medicine movement is all over the map politically. Back in the 1960s-1980s, the alignment of the FDA and FTC with the “health fraud” movement, and the general support of big government for big medicine created a powerful anti-government sentiment among many “alternative medicine” providers. Liberal Democrats like Henry Waxman focused on regulating the natural products industry, alienating others. Meantime, politicians on the right, like Dan Burton and Orrin Hatch, often supported “alternative medicine” and “health freedom” as consumer choice and opposed government regulation of the industry. Other politicians on the left, like Tom Harkin, began pushing integrative medicine as a part of systemic reform toward a wellness focus. Harkin and his colleagues inlaid integrative practice and complementary and alternative medicine in the ACA. Presently, Republicans are presently refusing to co-sponsor a bill to cover Medicaid payments for home birth (a choice issue, one way you look at it) because to do so would imply support for Big Government and Medicaid itself. Political leanings of the field are anything but monolithic.

I personally support the ACA. This is on one hand quite personal. I have had a health condition that would have had very crappy economic consequences for our family had we not had good health insurance. I wouldn’t wish lack of coverage on anyone. So I can hold my nose to a lot of other aspects of the law that i don’t much like to extend insurance protection to other human beings and their families.

I also support the present reform as the best option in a nation that didn’t have the good sense to go for single payer. (Do comparative outcomes with other nations mean nothing? Of course, the politics of evidence, in the U.S. is basically nothing more than the evidence of politics.) Finally, I support the law out of professional self-interest and related personal pleasure. Language inlaid in the Affordable Care Act, noted above, put licensed complementary and alternative professions or some variant of integrative practice, integrative practitioners and licensed members of integrative practice professions into federal policy for the first time. It is a pleasure after 28 years of working from a position of significant disenfranchisement to now be working on reform with a footholds on the inside. Complex stuff, for our fields as for the nation itself. It will be interesting to see what Goldman’s survey will find.

Wostrel: new IHPC exec

Alyssa Wostrel named executive director of the Integrated Healthcare Policy Consortium

The leading multidisciplinary organization lobbying for advancement of
integrative healthcare at the federal level, the multidisciplinary Integrated Healthcare Policy Consortium (IHPC), has announced that Alyssa Wostrel, MBA, DIHOM will be its new executive director. The release notes that Wostrel brings to the job more than a decade of experience in marketing
and organizational leadership positions within the natural products industry. The release notes that Wostrel “is
skilled in development and fundraising, including as Chair of the fundraising
committee for the American Medical College of Homeopathy, where she focused on
cause-related marketing at both the community and national level.”  She remains actively involved as a Board
member. States Wostel: “My
for-profit career offered rewarding work, but I also wanted a deeper purpose. So,
I’m excited to bring more visibility and awareness to IHPC’s groundbreaking
accomplishments in the legislative arena of integrative healthcare.” Wostrel succeeds former IHPC Executive Director,
Janet
R Kahn, PhD who remains involved as IHPC’s Senior Associate. IHPC states that the organization and it Partners for Health represent more than 250,000 licensed
integrative health care providers including medical doctors, naturopathic physicians,
acupuncturists, chiropractors, massage therapists, professional midwives, and homeopathic
practitioners.

Comment: Here’s hoping that Wostrel will have the tenacity, creativity and fundraising chops to allow IHPC to fulfill on its promise for integrative health care.

Insurance

Perlman: changes at Duke

Duke integrative medicine moves to insurance model

In a change from past practice, on March 15, 2012, Duke Integrative Medicine began accepting insurance “for all
physician consultations and many health psychology services.”
Duke’s director Adam
Perlman, MD, MPH states: “We are
tremendously excited to be able to make our services available to more
people than ever, now that we are enrolled in the insurance plans of
most of the people who live in the Triangle and beyond.” The program’s
statement about the change describes the patient process:

“A
physician consultation at the [integrative medicine] center is a comprehensive evaluation by
an expert Duke physician who is trained in conventional and
complementary medicine.  It
offers a complete assessment of a patient’s physical, emotional, and
spiritual health during which the physician takes the time to listen to
and understand a patient’s health concerns and goals.  The
physician works in partnership with the patient and his/her other
physicians to create a plan including the very best treatments available that aims to
optimize health and well-being. [Italics added.] At the time of any appointment, the
patient has full use of all of the Duke Integrative Medicine facility
including spa, whirlpool, sauna, steam room, library, meditation spaces,
walking labyrinth, and more.”

Comment: It is no surprise that
this change came after the arrival of Perlman. He recently transited to
Duke from the integrative medicine program at the University of Medicine and Dentistry of New Jersey,
a public university serving an under-served population. Another change
that may yet come as Perlman’s stamp goes on the program is away from
the physician dominance displayed in the language in this announcement.
The program has 7 MDs and some 30 other providers. These include massage
therapists, acupuncturists, mental health counselors, health coaches,
yoga teachers, exercise therapists, mindfulness educators). One would
never know this diversity exists, or that these representatives of
distinct disciplines were even present, from this language: “The physician works in
partnership with his/her other physicians …” Are the MD physicians not in partnership with the others? Is that not worth noting? Perlman, a past chair of
the Consortium of Academic Health Centers for Integrative Medicine, is known to be an exceptional collaborator and advocate for respectful relationships between integrative medicine and licensed CAM providers. He may need to give an in-service to his colleagues on respectful language.

High client satisfaction, perception of savings

Portland, Oregon’s managed CAM business announces high patient satisfaction, suggestions of cost savings

The
CHP Group (CHP) of Portland, Oregon announced March 12, 2012 that it is “thrilled” to release outcomes of its 2011 patient satisfaction survey. CHP looks at patient experience of chiropractors and acupuncturists and naturopathic doctors and others through questions
from the Consumer Assessment of Healthcare Providers and Systems (CAHPS)
developed by the US Agency for Healthcare
Research and Quality. The CHP Group also adds additional questions developed
internally by the firm to explore cost and quality issues in the integration dialogue. On the basic CAHPS, the firm’s overall score for
2011 was 96%, consistent with its outcomes since 2000, according to the
release. In addition, the CHP-developed questions found that:

• 98% of respondents replied “always” or
  “usually” to the question “Has the treatment or recommendation you
  received from this provider helped you?”
  
• 82% answered “usually” or “always” to: “Has the treatment
  or recommendation you have received reduced your use of prescription
  drugs?”
  
• 92% of respondents answered “usually” or
  “always” to: “Has the
  treatment or recommendation you received reduced your use of other
  medical care for this problem?”

States Michell Hay, CEO of The CHP Group: “We are
well aware of the high-quality of care our network providers render to
their patients, but it is gratifying to see patients acknowledge the
beneficial outcomes of the quality care they received.”

Comment: I find it astonishing that the prejudice or corrupt incentives of the present system limit affirmative exploration of the patient experience behind these data. Are patient perceptions so belittled that a finding that 82% perceived experience of decrease in drug use is discounted and unexplored? Do they judge worthless that 92% of these human beings said they reduced medical costs elsewhere through services of CHP’s CAM networks? All integrative practitioners
who do any kind of outcomes work should gather these data from these 3 questions. Why don’t the employer, payer or research
communities find these findings worth exploration? My default answer is that it does not serve the dominant school of medicine
to affirm the value of another discipline. Am I missing something?   

Academics

Nedrow: from OHSU to Duke

Anne Nedrow, MD to leave Oregon Health Sciences to launch primary care program at Duke Integrative Medicine

Oregon Health Sciences’ integrative medicine leader Anne Nedrow, MD, MBA is leaving the institution to become associate medical director at Duke Integrative Medicine. The position begins June 1, 2012. According to Isabell Geffner, communication’s director for the Duke program, Nedrow “will be responsible for administrative
oversight of all of our clinical initiatives. She adds that “her first priority [will] be the launch of our primary care practice in July, 2012.” The new program will be called PRIMARY CARE @ Duke Integrative Medicine: New Dimensions
in Health and Healing. Geffner notes that the practice will be
a “retainer [concierge] model in which patients will pay a nominal annual fee ($1500).” For this they’ll receive:

• Full
  primary care services
• Evidence-based
  complementary and alternative medicine treatments as appropriate
• 24-hour/7-day-a-week access to your physician
• Same
  day or next day appointment
• Personalized Health Plan
• Group-Based Integrative
  Health Coaching

Geffner notes that the change is linked to the program’s movement to accept insurance for all physician consultations and
select health psychology and nutrition services, noted above. Nedrow joins Adam Perlman, MD, MPH, the Duke IM leader. She’ll also have research and development responsibilities.

Comment: Nedrow’s move joins her with Perlman, another long-time leader of the Consortium of Academic Health Centers for Integrative Medicine. Nedrow’s cross country move also joins two of the medical doctors in that field who have most embraced the interprofessional and multidisciplinary forms of that field’s self-expression. Nedrow was the prime mover behind the Oregon Collaborative for Integrative Medicine (OCIM), which links OHSU with chiropractic, naturopathic and acupuncture schools in Portland. Nedrow also provided the cover of her license for the integrative services practice at OHSU. Nedrow’s exit will be felt. Meantime, it is fascinating that two individuals known as interdisciplinary collaborators are located at an integrative medicine program principally funded by an angel, Christy Mack, who is famous for not only MD-centrism but for routinely publicly denying – or so it seems to me – the CAM roots of “integrative medicine.” I view Nedrow’s appointment as a kind of healing.

IPEC’s Core Competencies document

Team care, interprofessional education and the move to give medical schools ownership of collaboration

Comment: The long-overdue movement toward team care in the academic medicine environment is
called interprofessional education (IPE). As
a nominally patient-centered movement, IPE would seem an exceptional
arena for better collaboration between medical doctors and other allied
health professionals including those not yet formally considered “allied health” such as chiropractors, naturopathic doctors and licensed acupuncturists. The March Integrator Round-up reported the unsettling movement “from dictatorship to oligarchy” in the formation of the Interprofessional Education Collaborative (IPEC)
by the Big disciplines of medicine, nursing, public health,
osteopathy, pharmacy, dentistry. The formation of IPEC was effectively a decision to not empower a separate US IPE organization had no discipline boundaries.

In March, the weekly bulletin
from the American Association of Medical Colleges (AAMC) has announced
that the Josiah Macy Foundation is funding an IPE web-portal. The decision follows the same pattern. Rather than launching it through the interdisciplinary American Interprofessional Health Collaborative that has no discipline boundaries, they placed it squarely in the lap of the profession that has most resisted collaboration in the American Association of Medical College (AAMC). The launch is presented as a collaboration with the other 5 of the Big 6. The launch also takes a positive step in noting that the American
Psychological Association, Physician Assistant Education
Association, and American Physical Therapy Association are to
collaborate
on the portal. The AAMC note states that “published resources
will serve as the initial content for the interprofessional portal and
resource collection, scheduled for release in March 2013 on the AAMC’s MedEdPORTAL.”

The direction of all this work is good. Perhaps I
simply live with too great a legacy of mistrust of medicine’s former dictatorship to be comfortable with
the dominant school as the first among equals; as, effectively, the primary steward of interprofessional collaboration. Why not let the medium be the message and place to with the AIHC or even the Canadian Interprofessional Health Collaboration which has already developed a Wiki on the subject? Then again, Macy might have been betting that the way to get the MDs to buy in was to put them in the driver’s seat. Good money suggests that IPEC will take the wind, as in cash, out of AIHC’s sails.

Manahan: questioning the control of IPE

Comment from Integrator adviser Bill Manahan, MD: Holistic medicine leader and family medicine educator Bill Manahan, MD sent a comment on my posting on this subject in March. He sited my concluding paragraph:

“Here is the paragraph you wrote: A colleague who is a
seasoned academic veteran urged time and patience. She shared her willingness
to accept this as a step in the right direction for these typically silo-ed
guilds. Yes, this is good. But why begin without the mind, spirit, treatment of
the body and access to community services fully included– via
psychology/mental health, PT/chiropractic/massage and social work — not to
mention the other licensed integrative practice fields. I will learn more about
this soon and report back whether my concern is valid that this was less a
“patient-centered” move than a “profession-centered” power
play to limit and control the emergence of democracy among professions. In
place of dictatorship, oligarchy. I hope I am wrong. 

Then Manahan added his comment:

“In my opinion, your concern is valid. I do not believe that those
six professions do not exclude other groups such as PT, DC, ND, MSW,
psychology, etc on purpose.  It is that they do not know enough
about them to even understand that they are excluding them. Ignorance is bliss – but sometimes not all that healthy.  The silo
those professions exist in is so tight and exclusionary that it does not
even enter their world view to include those other disciplines in their new
group.  In their thinking, it would be similar to the college sports team
including the high school sports team on their roster. Anyway, my experience has been that the majority of our
MD/DO/RN/Etc. colleagues are good people who don’t have a clue!”

Comment on Manahan’s comment: The good news in the roll-out of the website is that there is a good sign of a “clue” having been found. The psychologists, physical therapists and physicians assistants have at least been invited to dinner, if at the kiddies table.

Significant economic contributor

National College of Natural Medicine reports the institution’s $56-million contribution to Portland, Oregon economy

A study of the impact of National College of Natural Medicine (NCNM) on
the Portland, Oregon economy by ECONorthwest found a $56-million contribution. The
institution, with 550 students studying naturopathic medicine and
Classical Chinese Medicine, contributed in these ways: $25,815,000 in
direct spending on payroll and other operating costs,
capital spending, and student spending on food, rent, entertainment and
other expenses within the city; $10,883,700 in indirect or supply-chain
spending related to the college’s purchases of goods and services from
local businesses; and $19,160,700 in other spending resulting from the
enhanced purchasing power of households directly or indirectly affected
by NCNM’s economic activity.” Altogether these impacts were estimated to have generated 613 jobs
and contributed $55,859,400 to the local economy.

Comment: Bastyr University carried out a
similar study last year. My guess is that these millions will make some
of Portland’s leaders who were formerly skeptical about
non-conventional care begin to think that there just might be something
to it. This is bound to have a nice placebo effect on the Portland Chamber
of Commerce. Notably, the college was subsequently featured in the local business media laying out an ambitious master plan.  

Tai Sophia’s Frank Vitali

Frank Vitale’s frank explanation of Tai Sophia’s transition from the “academic wellness institute” toward university

Maryland’s Tai Sophia Institute is poised to become a university. Institute president Frank Vitale made an unusual decision to publicize and post a transcription
of his meeting with his leadership team on the transition of what
founding president Bob Duggan used to call an “academic wellness
institution.” Vitale positioned the action this way: “The field of
integrative medicine is growing and Tai Sophia needs to remain in the
forefront in its evolution.” Tai Sophia’s move toward university status began in 1998
and is expected to be completed in 2-3 years. The university status is
expected to confer prestige on diplomas. Vitale also shares that the
school is still carrying too much debt for an
institute of its size. Vitale and his team have been exploring an array of strategic
partnerships.

Comment: The positioning of this institution as “integrative medicine” may come as a surprise to the authors of the recent Bravewell mapping report. That noted, overall, the
piece feels a bit like voyeurism even as I respect Vitale’s forthright
presentation of the issues. How well the radicalism
of the Institute’s original message be maintained as it gains the trappings of a university? The tendency in
the universification of the school will be a regression to a very conservative mean. An “academic wellness institution” seems easier to maintain on mission than an
“academic wellness university.” Here is hoping that Tai Sophia holds on
to the advocacy of a wellness model as it builds into this conventional
framework. A wellness university is exactly the kind of innovation in health professional education that we need.

School seeks Director, Nutrition & Integrative Health Program: Tai Sophia’s provost and executive vice president Judith Broida, PhD separately sent a note that the institute is looking to fill this leadership position. Information is here.  

Horse needling: LSU veterinarian school goes integrative

The March 2012 Integrator Round-up included a brief note entitled Insurance coverage of alternative therapies on the rise … for pets!. Now comes news that the LSU Veterinary Teaching Hospital has
“broadened its services to include acupuncture, massage therapy and
herbal treatments for animals — the large ones for now and dogs and cats
soon.” Associate professor of veterinary medicine Rebecca McConnico
notes that horses seems to be particularly amenable to acupuncture. She
notes that she has “worked with about two dozen animals since her
recent certification, including horses, goats and cattle.” The reception of the new program has been good: “It
seems to be well-received. Some clients just ask for it and sometimes
it’s offered to them. Most are willing to try it.” The initial consult
to see if the animal is right for the care costs $40. An acupuncture
treatment is $100.

New York Chiropractic College: pioneering VHA residency

New York Chiropractic Colleges announces the Veteran’s Administration’s first chiropractic clinical residency

The Seneca Falls-based New York Chiropractic College announced in late March the establishment of
“an integrated care chiropractic residency program.” According to the release, this is “the first such program to
be located at a Veteran’s Health Administration (VHA) facility.” NYCC has been running several academic and research
programs at the Canandaigua, NY, VHA site. The residency is anticipated to prepare the College’s chiropractic clinical residents for optimal
management of patients with a diversity of musculoskeletal disorders. Executive vice president and provost Michael Mestan, DC stated:“The new groundbreaking VA residency
program significantly complements the College’s existing offerings there.” Residents’ duties will
include working alongside the VA system’s established providers while providing rotations with specialists in neurology, orthopedics,
physiatry, pain management, primary care and physical therapy.


Natural Products

Proctor & Gamble buys herb company New Chapter

“Our
shared mantra is acquisition, not assimilation,” wrote the former owners
of the Brattleboro, Vermont-based New Chapter in
a letter to their employees that provided details about their purchase
by the world’s largest consumer products firm Proctor & Gamble
according to a story on the acquisition
posted by the American Botanical Council (ABC). New Chapter’s founders, Barbi and
Paul Schulick state: “Our culture,
guiding principles, and credo will not change and will only be buoyed by
the superlative values gleaned from Procter & Gamble’s resources
and experience.” The firm, founded in 1982, had a history of partnering
with significant institutions for research on its products. States ABC
founder Mark Blumenthal: “There’s
probably no better evidence of mainstream consumer acceptance of the
benefits of herbal dietary supplements than P&G’s acquisition of New
Chapter. Obviously, Procter & Gamble has done a significant amount of due
diligence in researching not only New Chapter’s history and product
quality but also in determining the future growth potential for New
Chapter’s herbal and other dietary supplement products. A company like
P&G doesn’t make such a strategic move into a new area like dietary
supplements without a considerable level of research.” No price was disclosed.

Comment: The first phase of complementary and alternative medicine integration, in the late 1990s, saw a rash of ventures by
big pharma into the botanical trade. This is the first significant
re-entry in some time. New Chapter is distinctive in its combination of
Vermont back-to-land herbalism and research savvy.

Integrative Care

Article suggests “integrative oncology” is often non-integrated, parallel practice

Integrator adviser and integrative oncology consultant Glenn Sabin of FON Therapeutics sends note of a March 15, 2012 article in the ASCO Post (American Society of Clinical Oncology) entitled Some Patients Using Complementary and Alternative Therapies May Be Receiving ‘Parallel’ Rather Than Integrative Care. The article by Charlotte Bath focuses on a study by University of British Columbia researcher
Lynda Balneaves, RN, PhD. She concludes: “For most
individuals, true integration is not occurring.
Complementary, alternative medicine and conventional care are being
provided in parallel systems by health professionals who are not
consulting each other.” Balneaves presentation was at the 2011 meeting of the Society
for Integrative Oncology (SIO). Balneaves also found that integration is desired by patients. She is quoted as saying that patients wished “to have
complementary and conventional care combined.” She added that one woman
described integrative care as “like an orchestra – everyone is working
together and there is synergy.”

Comment: The finding is not surprising. And, 15 years ago, the finding of any integration would have been shocking. Here’s to recruiting to the orchestra.

Midwives – regular referers to CAM practitioners

The (intense) home birth midwifery model of integration with other CAM fields 


At Symposium 2012 of the Certified Professional
Midwives (CPM) and Association of Midwifery Educators (AME), I asked the
roughly 150 midwifery leaders assembled for a shows of hands of those who had “used or referred for” the services of acupuncturists? What
do you think the percent would be? For chiropractors? For AOM?
For massage? For naturopathic doctors?  The answer: virtually all arms
shot up with each question, at close to
100%. The only fall-off was for NDs,
who are only licensed in 16 states, but still at perhaps 80%.

Comment: I was quite surprised to see how profoundly integrated these practices are with the other natural health disciplines. I queried a couple of colleagues who were similarly surprised. I’d have guessed 30%-50% for each, except for massage. The suggestion here is that this field incorporates perhaps the most thorough approach to team care of any health care field. It’s too bad that more obstetrician’s don’t allow the home birth midwives to comfortably round out their care teams.

Bauer: Mayo’s IM leader

Mayo Clinic takes alternative medicine to Mall of America

One of the biggest names in medicine has linked with the biggest mall in America to feature integrative medicine (Mayo Clinic’s focus on integration on display at Mall of America).
Mayo already had one clinic in the Mall. The second will offer a
variety of integrative services “that we already offer on campus,”
Mayo’s integrative medicine leader Brent Bauer, MD is quoted as saying.
Adds Bauer of the Mall gambit:
“There seems to be quite a bit of demand (at the Mall). It’s a nice
place to kind of test, and push a little
bit, the idea of how do we promote wellness.” According to the article the clinical site now includes acupuncture, massage therapy and counseling about supplements.

Seely: heading major naturopathic oncology initiative

Canadian College of Naturopathic Medicine opens oncology research center

The Canadian Colleges of Naturopathic Medicine (CCNM) has opened
the first integrative cancer center in Eastern Canada, according to a March 26, 2012 release. The Ottawa Integrative Cancer Centre
(OICC) will provide “multi-disciplinary complementary
medicine and whole-person care for people with cancer, and to those
wanting to prevent cancer or its recurrence.” The center, which will feature both clinical services and research, is led by
Dugald Seely, ND, MSc, FABNO.
Seely is also the director of research and clinical epidemiology at
CCNM. The release notes that Seely “has helped to
establish CCNM as one of North America’s leading research center in
complementary medicine.” The program “has two pillars: clinical trials
of complementary
therapies and evaluating integrative whole-systems of care.” The work is
expected to be integrated with conventional treatment and is anticipated to benefit from Seely’s extensive relationships developed as an affiliate investigator at the Ottawa
Hospital Research Institute (OHRI) where he has “a number of collaborations
with OHRI scientists.”

Comment: Seely is developing a fine
body of work, particularly in the whole practice, whole systems
examination of naturopathic care. See Model Whole Practice Study Finds Naturopathic Care Effective, Cost Saving for Canadian Employer.
Notably, the release includes a supportive quote from the Ottawa
Regional Cancer Foundation, which anticipates collaborating with the
OICC. Kudos to Seely, CCNM and all parties involved. We can expect a good deal
from this operation.

Bravewell Collaborative makes November 2011 symposium talks available

The Bravewell Collaborative has made public a series of significant presentations at their November 2011 Integrative Medicine in Action
seminar. Those video-taped include integrative cardiologist Mimi
Guarneri,MD; Col. Kevin Galloway of the US Army Pain Management Task
Force; Tracy Gaudet, MD from the VA; F16 pilot and health coach Lt.
Wendy Hendrick; Allina CEO Ken Paulus; and Allina chief medical officer
Penny Wheeler, MD.

Comment: The Bravewell program was a
well-assembled and powerful testament to integrative medicine in both civilian and military environs. Particularly
compelling were the comments of Paulus, speaking about how integrative medicine has become his ally since, for the
first time in 100 years, Allina can “get paid to keep the village healthy.”  

University of Toronto awards spine professorship to chiropractor

The University of Toronto has awarded the Canadian Chiropractic Research Foundation (CCRF) Professorship in
Spine to Carlo Ammendolia DC, PhD. The professorship is funded with an initial investment
of $500,000 from CCRF in a partnership agreement between the CCRF and the University of
Toronto. The new
“Research Professorship in Spine” will have its home in the Faculty of
Medicine. Ammendolia is a clinical epidemiologist and assistant professor in the Institute of Health Policy, Management and Evaluation at the
University of Toronto. This is the 12th research chair or professorship to be funded through CCRF.

Comment: I have a couple queries out as to gain clarity on how CCRF funds these. What I recall from informal conversations is that in the Canadian system, the structure of professional organizations is quasi-governmental, and, as such, as I recall, associations can have coercive powers to require contributions. Huey Long, the master of the “deduct,” would like this. I, by the way, do too.

Acupuncture association reaches out to secure more submissions to their professional journal

The American Association for Acupuncture and Oriental Medicine is actively reaching out to beef up submissions to The American Acupuncturist, its journal. According to a statement available here,
the professional association is “aggressively pursuing a goal of being
indexed by Medline.”  Details for submission to the quarterly are here.


Short Notes on integrative care in the nation’s hospital and health systems

These briefs arfe from Google Alerts: Beth Israel director of integrative medicine talked up the value of probiotics on KXLY radio … The Parkview Physicians Group in Fort Wayne, Indiana announced a new integrative medicine program. It will be led by Angella LaSalle, MD, a University of Arizona Fellow in Integrative Medicine … Patrick Massey, MD, PhD, the medical director for complementary and
alternative medicine for the Alexian Brothers Hospital Network  promoted “bioenergy healing” in the Illinois Daily Herald” … Kaiser Northern California integrative medicine leader Catherine Gutfreund, MD was named Sonoma County Family Physician of the Year … Acupuncture,yoga and Tai chi are featured public education programs over the next 3 months at the Osher Center for Integrative Medicine at Harvard University ... Integrative Medicine for the Underserved (IM4US)
has made available a powerpoint on introducing integrative medicine to faculty … Mercy Health posted back integrative content from the Springfield, Missouri system’s integrative medicine leader Lance Luria, MD of Mercy … Integrative medicine is one of the subjects at Stamford Hospital’s mini-medical school … Sierra Tucson has linked with Univresity of Arizona to help educate students their integrative programs for treating addictions … OhioHealth promotes its integrative medicine program– but without any evidence of who the providers may be …

Media

Sita Ananth: translating military IM to civilian use

Can community hospitals learn integration from the military?


The column in the American Hospital Association’s Hospitals and Health
Networks magazine by Samueli Institute’s knowledge leader Sita Ananth,
MPA and Leila Kozak is entitled “Complementary and alternative medicine within the VA system.” The subtitle states: “Community hospitals can learn from the success of efforts to integrate CAM into veteran services.”
The article notes that a 2011 survey found that 89% of VA facilities
offer some kind of complementary and alternative medicine. This is more
than double the 42% in community hospitals found in a 2010 survey.
Chiropractic has already been “re-classified as mainstream
practice.” According to the authors, the other area of significant use
of complementary care in the military is
mind-body treatment, for an array of disorders. Samueli Institute is the
nation’s leader in partnering with the military on integrative
strategies. 

Comment: Growing up in what used to be
called “Boeing country” (Seattle), we always heard plenty about the
transfer of high technology from military and space programs to civilian
use. So forgive me if technology transfer from the military to civilian
hospitals of mind-body therapies and chiropractic feels an oxymoron.
Who would have thunk it? Nice piece.

Wallstreet Journal boosts massage as medicine and as stress reduction

The title of the March 13, 2012 story was “Don’t Call it Pampering: Massage Wants to Be Medicine.”  While condescending in title, the article’s review of the field and recent findings reads almost like a media brief on behalf of the profession – and not just as focused “medicine” but also in reducing stress. Included was reference to the osteoarthritis research led by Adam Perlman, MD, now director of Duke Integrative Medicine. NIH NCCAM’s deputy director Jack Killen, MD was quoted this way: “There is emerging evidence that [massage] can make contributions in
treating things like pain, where conventional medicine doesn’t have all
the answers.”

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

1.  Elizabeth Sommers, PhD, MPH, LAc: “For the next stage, a more representative slice …”

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

2. Mitchell Prywess, MD: “My hope is that we avoid turf battles …”

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

3. Michael Levin: “This disciplined subset of integrative medicine is amenable to research and quantification”

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.

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

5. Bill Manahan, MD: “There is a completely different world of integrative
medical care being practiced in private offices … “



 

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

7. Jim Winterstein, DC: “An interesting read, but so what?”

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.

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.

• Patient-Centered Outcomes Research Institute draft plan comment period ends March 15: No CAM-IM presently included
  

International

• Dana Ullman, MPH: Swiss government finds homeopathy cost-effective, covers in national health plan
• Update: Marilyn Allen and the advancing effort to place TCM in World Health Organization’s ICD11 codes

Integrative Centers

• Bravewell publishes landmark Integrative Medicine in America (but does the subject matter reflect the title?)
• University of Minnesota’s Center for Spirituality and Health sets sights on “whole systems healing”

Academic Health

• Six profession organization enters the team care/interprofessional education space: from dictatorship to oligarchy?
• Consortium of academics in licensed fields of chiropractic, AOM, naturopathic medicine, massage and midwifery receive a breakthrough $100,000 grant from the Westreich Foundation

Costs & Coverage

• Aetna’s mind-body programs developed in partnership with Duke, Viniyoga and e-Mindful
• Swiss analysis finds those with CAM services cost the same or less than conventional care, with higher patient satisfaction
• Insurance coverage of alternative therapies on the rise … for pets!

Professions

• NCQA to “score” Vermont’s naturopathic doctors in medical homes, according to report from Vermont’s Lorilee Schoenbeck, ND
• American Chiropractic Association House of Delegates chastise some chiropractors in effort to position the profession for primary care role

• 
  Notes from the 2010 annual report from the National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM)
• Effort underway to revitalize National Association of Nurse Massage Therapists
• Foot Levelers, major donor to chiropractic PR effort, pledges additional million dollars

Business

• Global Advances in Health and Medicine, launched by veteran team, to focus on case reports
• The Joint … a chiropractic place: Massage Envy franchise model developed to offer low-cost adjustments
• An early peer-reviewed publication in this space, Alternative Medicine Review, faces challenges

People

• Kara Kelly, MD elected to presidency of Society for Integrative Oncology
• Christine Goertz, DC, PhD honored as Chiropractor of the Year
• Botanical resource from Roy Upton and the American Herbalist Pharmacopoeia honored by the American Botanical Council
• Daniel Redwood, DC begins new health policy blog

Calls for public comments

Patient-Centered Outcomes Research Institute draft plan comment period ends March 15: No CAM-IM presently noted

The Patient-Centered Outcomes Research Institute (PCORI)
has called for comment on the new agency’s draft plan. The comment period ends March 15, 2012. PCORI was
established under the Affordable Care Act in part to promote comparative effectiveness research (CER).
The plan shares methods through which the new quasi-public agency is expected to
dispense over $600-million a year in research funds. The agency has been viewed by some in the integrative practice
community as potentially more open that the National Institutes of
Health to the kind of pragmatic research that may capture
the whole practices of integrative care. However, the draft plan includes no references to complementary and alternative or integrative medicine, practice or practitioners. Go to this link to read PCORI’s 22 page plan. Go to this site for PCORI’s online public response form.

Comment: Through my work with the Academic Consortium for Complementary and Alternative Health Care (ACCAHC), I have been involved with a team in tracking PCORI activity. Inside ACCAHC, we take
the position that, at this point in the evolution of U.S. health care,
if “complementary and alternative medicine” and “integrative medicine”
or “integrative health” are not explicitly included in a guidance document, these practices and disciplines
are not likely to be in the minds of readers as part of any recommendations or future actions. We have urged explicit inclusion in two prior responses and September 2011 when two of us had a chance to present
to the Board of Governors.

There is significant precedent for explicit inclusion. A June 2009 Federal Coordinating Council report on
CER listed “complementary and alternative medicine” as a topic for CER. More importantly, the March 2010 Congressional
mandate in Section 6301 of the Affordable Care Act

that established PCORI explicitly states that a “state-licensed
integrative health practitioner” should be among the members of the
Board of Governors and that an “expert advisory panel” should include
“experts in integrative health.” This draft plan lacks any direct
references. Time to get the language in there. Go here to comment.

International

Dana Ullman, MPH

Dana Ullman, MPH: Swiss government finds homeopathy cost-effective, covers in national health plan

In the Huffington Post article The Swiss Government’s Remarkable Report on Homeopathic Medicine, author-advocate Dana Ullman, MPH has again shown how homeopathy’s minimal dose can somehow generate enough energy to heat up the internet. Ullman’s review of the Swiss government’s review had generated some 800 comments and 3500 Facebook shares as of March 3, 2012. Ullman writes that the report’s authors cite evidence-based medicine pioneer David Sackett, MD in their method for choosing useful research. Sackett dismisses those who argue that randomized controlled trials are the only meritorious evidence. Writes Ullman: “Ultimately, the Swiss government’s report on homeopathy represents an
evaluation of homeopathy that included an assessment of randomized
double blind trials as well as other bodies of evidence, all of which
together lead the report to determine that homeopathic medicines are
indeed effective.” Those using homeopathy had 15.4% lower costs. After suspending coverage in 2005, the Swiss government has now reinstated it.

Comment: Nothing stimulates the paradigm wars quite like homeopathy and Ullman’s Huffington Post writing on the topic is continuously a battle ground. He pointedly opened his piece with reference to Switzerland’s vaunted neutrality. Another of that country’s signature attributes is now also in play for homeopathy: the report may be viewed as a Swiss bank account from which homeopathic advocates can spend to advance initiatives all over the world. Ullman’s article was a first big draw from the Swiss account.

AOM activist Marilyn Allen

Update: Marilyn Allen and the advancing effort to place TCM in World Health Organization’s ICD11 codes

A note recently from Stacy Gomes, EdD, MAEd, VP of academic affairs for Pacific College of Oriental Medicine shared this: “Marilyn Allen’s quiet but steadfast work as the
U.S. liaison for the WHO ICD11 [International Classification of Diseases, 11th edition] codes should be on the Integrator Top 10 list but it has not been publicized well
and it only effects a limited ‘traditional’ medicine. It is a VERY
promising direction for diagnostic coding for Chinese medicine.” Gomes’ note accompanied news that a new “ICD Alpha Browser” of the coding strategy is presently available on a WHO site. The TCM portion is here for review and comment by those who register. Here is a taste of the new language and approach:

“Key Definitions in ICTM [International Classification Traditional Medicine]:

“A disorder in traditional medicine,
disorder (TM)*, refers to a set of dysfunctions in any of the body
systems which presents with associated manifestations, i.e. a single or a
group of specified signs, symptoms, or findings. Each disorder (TM)
may be defined by its symptomology, etiology, course and outcome, or
treatment response.

“1 Symptomology: signs, symptoms or
unique findings by traditional medicine diagnostic methods, including
the taking of the pulse, examining the tongue or any tongue coating,
abdominal examination, and other methods.

“2 TM Etiology: the
underlying traditional medicine explanatory style, such as weather
factors (historically known in TM translations as the external
contractions), emotional factors (historically known in TM translations
as the seven emotions), or other pathological factors, processes, and
products.”

Comment: Gomes is right to credit Marilyn Allen for this work. Allen has led the charge for years now to raise funds to get the U.S. acupuncture community into the room to help develop these codes with counterparts and colleagues in China, Korea and Japan. Allen is an educator and writer who also serves as director of marketing for the American Acupuncture Council, a malpractice insurance provider. Allen’s view of the importance of this process is available here. Stacy you are right: Marilyn is perfect for the Top 10 for 2011 list.

Integrative Centers

Mapping health system integrative centers

Bravewell publishes landmark Integrative Medicine in America (but does the subject matter reflect the title?)

In mid-February 2012, the Bravewell Collaborative of philanthropists in integrative medicine published Integrative Medicine in
America: How Integrative Medicine Is Being Practiced in Clinical Centers Across
the United States. The report is based on survey-and-interview-based research in 29 health system and
academic medical center-sponsored integrative medicine clinics. The 114-page document includes extensive data on types of services, conditions
treated, and perceptions of leaders on where services have the most
clinical value. (Topping the list was chronic pain.) The publication
generated substantial media attention for the
emerging field. A Huffington Post article on the study is here:

New Bravewell Report a Goldmine for Those Intrigued by Integrative Medicine, Pandora’s Box to Skeptics.

Comment: This study is tremendously
interesting to anyone who cares about integrative medicine. It’s truly a
treasure trove of riches into which one can dig and then mull. Click in and check it out! I had one significant concern which I addressed with a posting query: Integrator Forum: Does the
Landmark “Integrative Medicine in America” Actually Portray Integrative
Medicine in America? The reason: The vast majority of consumer experience of “integrative medicine in
America” is through community-based practices. Does this portrait capture what a consumer
is likely to experience – or what an integrative medicine practitioner
offers? Is the field appropriately represented in this report? What would be different if such a report were based on
surveys of community-based practices? If you have an opinion, send it to

johnweeks@theintegratorblog.com and it will be included in an upcoming
Integrator forum.

Mary Jo Kreitzer, RN, PhD, FAAN

University of Minnesota’s Center for Spirituality and Health sets sights on “whole systems healing”

An exceptional February 11, 2012 keynote by Mary Jo Kreitzer, RN, PhD, FAAN at the Integrative Healthcare Symposium (IHS) introduced participants to the Whole Systems Healing (WSH) initiative of the University of Minnesota’s Center for Spirituality and Health, which Kreitzer founded and directs. The initiative, engaged in partnership with the Life Science Foundation, describes WSH as “a way of cultivating the health and well-being
of individuals, communities, organizations, societies, and the
environment by living and acting with awareness of the wholeness and the
interconnectedness of all living systems.” Among the WSH “Strategies and Practices” explored on the site are: Gentle Action, Social Entrepreneurship, Reflective/Contemplative/Spiritual Practices, Interpersonal Relational Practices, and Restorative Dialogue. A significant section is devoted to Whole Systems Leadership. Those interested can take a 50 minute module.

Comment: Making headway in creating a health and wellness orientation in our culture and our medical practices requires a tough acknowledgment for any practitioner; that is, what goes on in the clinic reflects a mere fraction of what contributes to one’s health or illness. One needs a systems approach. Our world needs more individuals who walk comfortably in the complexity of such a whole systems view. The integrative practitioner would seem a natural for such leadership, given the philosophy. But, as my colleague Pamela Snider, ND, likes to say, we need to “operationalize” our philosophy. Credit Kreitzer and her team, and their partners at the Life Science Foundation, for helping operationalize this connection for our community. Now, time to go take that whole systems healing leadership module!

Academic Health

First product of the IPEC group, pre-incorporation

Six profession organization enters the team care/interprofessional education space: from dictatorship to oligarchy?

The movement toward interprofessional education (IPE) and team care took a curious organizational step in February 2012. Academic organizations representing the six most significant health
professions (medicine, pharmacy, nursing, public health, dentistry and
osteopathy) announced that they have formed a new organization, the Interprofessional Education Collaborative (IPEC). The
release notes that “as a stand-alone entity, the new IPEC will provide
leadership around
national initiatives to advance interprofessional education (IPE) and
share information on IPE best practices and collaborative practice innovations.” The academic organizations for these six disciplines first came together under the IPEC
name in 2009 to develop a document published in May 2011 called Core Competencies for Interprofessional Collaborative Practice.

Comment: Normally I would greet news of
collaboration between medical disciplines with unrestricted positivity. It furthers us to cross the great water out of our guilds. But
the timing of this announcement looks like a power-play by a subset of professions to control what
was shaping up as a broadly inclusive movement. The image is of a transition from the historic dictatorship of care by MDs to a six family, biomedical oligarchy that may make second class citizens of other professions in the whole body-mind-spirit of quality care.

Here is context. Just last year, a project that has carried the IPE torch in the U.S., American Interprofessional Healthcare Collaborative, formally incorporated as a stand-alone entity. This group, closely connected with the pioneering (and Canadian government funded) Canadian Interprofessional Health Collaborative, has pushed IPE/C for years as an important shift in U.S. health care. The group, headed by Barbara Brandt, PhD, is inclusive. Among the board members, for instance, is CIHC leader, John Gilbert, PhD, a phonetician who founded the School of Audiology and Speech
Sciences at University of British Columbia. The work in Canada, which Gilbert leads, has included chiropractors and midwives.
The AIHC and CIHC organizations jointly promote the biennial Collaboration Across Borders conference. The conference surged in attendance in 2011 to roughly 700 from half that size
two years earlier. The felt sense among the long-time laborers in this
fields was that the movement had finally arrived.

As a participant in
that meeting on behalf of educators in integrative health care,
I experienced the openness and receptivity to the integrative health disciplines
participating in this nominally patient-centered movement. As one who
has known what it is to labor in obscurity and without two dimes to rub
together, I had hoped that the foundation community would finally bless and empower the AIHC work in a significant way. The work is important.

Yet it appears that the “Big Six” professions comprising IPEC are taking
that wind and inserting their professions in the movement’s driver’s seat. With announcement of the founding of IPEC organization came word of a May 2012 meeting. I clicked in: the May 2012 IPEC Institute was already announced as Sold Out!

The problem with this limited set of disciplines is that the whole person is poorly represented. Will this group insure there is space at the table
for psychologists? Social workers? Physical therapists? Chiropractors? Mental health counselors? Naturopathic doctors? Functional medicine
educators? Will members of other disciplines have any say over programs and organizational directions? Or have they decided that, for now, IPE is a 6 discipline game.

A colleague who is a seasoned academic veteran urged time and patience. She shared her
willingness to accept this as a step in the right direction for these
typically silo-ed guilds. Yes, this is good. But why begin without the mind, spirit, treatment of the body and access to community services fully included– via psychology/mental health, PT/chiropractic/massage and
social work — not to mention the other licensed integrative practice fields. I will learn more about this soon and report back whether my concern is valid that this was less a “patient-centered” move
than a “profession-centered” power play to limit and control the emergence of
democracy among professions. In place of dictatorship, oligarchy. I hope
I am wrong.

Consortium of academics in licensed fields of chiropractic, AOM, naturopathic medicine, massage and midwifery receive a breakthrough $100,000 grant from the Westreich Foundation

The Westreich Foundation
“broke the glass ceiling” that has kept significant philanthropic support for integrative health initiatives that are not run by medical
doctors. So asserts a February 29, 2012 release from the Academic Consortium for Complementary and Alternative Health Care (ACCAHC). The foundation, led by Ruth Westreich,
chose to give ACCAHC $100,000 over three years to support “the bridging
and collaboration [ACCAHC is] striving to accomplish across all fields
of quality care.” Ruth Westreich, the foundation’s president, states that the grant was made because:

“I believe that [ACCAHC] is playing a significant role in breaking down the
dreaded silos of individual groups and are able to envision the
greater, larger picture of a preferred patient-centered care model. I am
hoping that this grant will allow you even more time to create
collaborations between CAM [complementary and alternative medicine],
integrative medicine and palliative medicine.”

The funds will provide staff support for ACCAHC
initiatives which include, according to the release, “expanding
evidence-informed education,
enhancing competencies for optimal practice in integrated environments,
and preparing leaders in whole person health.”

Consortium in breakthrough grant

Comment: As a part of the ACCAHC team, I found the Westreich Foundation’s grant to be particularly good news. I will personally be allowed more time to work through
ACCAHC on networking and program development to help knit new relationships between the disciplines. It
remains a curious thing that long-time builders of the movement for
whole person, human-intensive, natural health approaches have
substantially been passed over since significant philanthropy entered the integrative medicine picture
15 years ago. Money has instead gone to the last players to arrive in the game; namely, the
academically-based integrative MDs. There is much good that has come of that priority. Witness the Bravewell study reported in this Round-up as an example.

But what are the optimal strategies to effect the transformation toward a wellness model of care? Change
can certainly come from the top down and often does. Yet strategies for leveraging transformation may also come bottom-up, through
empowering the already committed grassroots. In the integrative practice
movement, the most organizable grassroots are the 350,000 plus licensed CAM
practitioners who are delivering high-touch, integrative care daily.
What might be accomplished through better empowering these
professionals? Doesn’t a kind of pincer movement for integrative health make sense, enabling both top-down and bottom-up strategies? The Westreich Foundation grant represents a visionary breakthrough as a philanthropic contribution toward potentiating pent-up collaborative interest in these disciplines.

Costs & Coverage

Aetna’s mind-body programs developed in partnership with Duke, Viniyoga and e-Mindful

The February 2012 release from Aetna and its three partners was entitled “Aetna Delivers Evidence-Based Mind-Body Stress Management Programs.” The giant insurer is now offering its employees two workplace programs: Mindfulness at Work (mindfulness meditation) and

Viniyoga Stress Reduction (therapeutic Viniyoga). These were collaboratively researched by Aetna in partnership with Duke Integrative Medicine and the two delivery organizations. Pilot studies found that the programs helped
participants significantly reduce their perceived stress levels while
improving their ability to respond to stress.
Since completion of the 2010 study, Aetna has expanded the availability
of the programs to all Aetna employees nationwide. Aetna
also began implementing the programs with several employer
customers. The insurer indicates in the release that they have “received strong interest from other customers in a
wide range of sectors, including financial services and health care
service providers.”

Swiss analysis finds those with CAM services cost the same or less than conventional care, with higher patient satisfaction

A recently-published study, Comparison of Swiss basic health insurance costs of complementary and conventional medicine, based on a thorough governmental analysis, supports the cost neutrality or cost-effectiveness of complementary and alternative medicine. The study examined comparative cost effectiveness with what the researchers called conventional medicine (COM):

“Results: Statistical procedures show similar total practice
costs for CAM and COM, with the exception of homeopathy with 15.4% lower
costs than COM. Furthermore, there were significant differences between
CAM and COM in cost structure especially for the ratio between costs
for consultations and costs for medication at the expense of basic
health insurance. Patients reported better quality of the
patient-physician relationship and fewer adverse side effects in CAM;
higher cost-effectiveness for CAM can be deduced from this perspective.

“Conclusion: This
study uses a health system perspective and demonstrates at least equal
or better cost-effectiveness of CAM in the setting of Swiss ambulatory
care. CAM can therefore be seen as a valid complement to COM within
Swiss health care.

This study was a part of the decision process of the Swiss government upon which Dana Ullman, MPH, commented in his report in the Huffington Post noted elsewhere in this issue of the Round-up. (Thanks to Integrator adviser Paolo Roberti di Sarsina, MD for the link.)

Insurance coverage of alternative therapies on the rise … for pets!

The title of the article in the February 13, 2012 Seattle PI online as sent by Integrator adviser Glenn Sabin was intriguing: Trupanion Offers Coverage for Alternative Therapies. The subhead was as appealing: “Alternative therapies including acupuncture, physical therapy,
hydrotherapy, and behavior modification will now be covered under
Trupanion’s expanded benefits.” It
isn’t until one gets into the story that it becomes clear that Trupanion
is the nation’s second largest purveyor of health insurance policies
… for pets. The firm’s paradigm is one of “whole pet treatment.” For example: “Alternative therapies often complement traditional medical therapies to
assist in the treatment of accidents and illnesses. The focus is on
individualizing treatment, treating the whole pet as opposed to specific
symptoms, and promoting self-healing.”

Comment: I anticipate a rash of hiring of veterinarians by
integrative clinic to take advantage of this new
opportunity for income from covered services.

Professions

Lorilee Schoenbeck, ND: leads her profession’s dialogue with NCQA

NCQA to “score” Vermont’s naturopathic doctors in medical homes, according to report from Vermont’s Lorilee Schoenbeck, ND

The February 2012 issue of the newsletter
of the American Association of Naturopathic Physicians includes a
synopsis of medical home developments from a naturopathic perspective by Lorilee Schoenbeck, ND,
a leader of that profession in Vermont. Of particular note is the
effort of Vermont naturopathic doctors to gain recognition through the National Committee for Quality Assurance (NCQA), which accredits medical homes. Schoenbeck writes:

“NCQA:
The Medical Home Model is currently being promoted and accredited by a
national, private organization called the National Committee for Quality
Assurance (NCQA). Prior to the efforts of Vermont, the NCQA did not
acknowledge or ‘assess and score’ NDs as Medical Home applicants.
However, now through our state’s health reform agency, we have been
successful in having NCQA assess our clinics to provide scores. To date
the NCQA has not formally certified NDs. The assessment is a major
breakthrough and one we continue to use with our state legislature to
gain recognition.”

Schoenbeck has led successful efforts in the
state of Vermont to include NDs in insurance coverage and as primary care,
Medicaid-covered practitioners. She concludes her article to her naturopathic colleagues this way:
“At one time,
PA’s and NPs were not recognized by the NCQA. Pressure from the states
and state legislation changed this policy. NCQA recognition may be a way
‘in’ through health care reform for NDs wanting to maintain their
status as a PCP.”

Delegates pass pointed resolution

American Chiropractic Association House of Delegates chastises some chiropractors in positioning the profession for primary care role

According to this release on their February 2012 regular meeting, the American Chiropractic Association (ACA) House of Delegates approved a new policy supporting the organization’s efforts “to
position DCs as conservative primary care doctors who can help fill the
looming primary care workforce gap.” The policy reads:

“Public Health Concerns Due to Failure to Differentially Diagnose. ACA
condemns as a threat to public health the failure by doctors of
chiropractic/chiropractic physicians to adequately differentially
diagnose and/or to sell treatment packages in the absence of a
differential diagnosis. Such practices are contrary to the doctorate
level of education inferred by our degree. Furthermore, they are
contrary to the universally accepted standards of care and do not
represent the customary practices of a member doctor of this
organization.”

The meeting also included a discussion among nine chiropractic college presidents about the doctor of chiropractic as a primary care provider.

Comment: The position of chiropractic doctors relative to primary care is a challenge on many fronts. On one hand, some chiropractic colleges train these professionals for the broad scope practice of what they prefer to call “chiropractic medicine.” On the other are those who find any connection of “chiropractic” to “medicine” an utter violation of the profession’s core values. This ACA resolution appears to be a slap to the subset of the latter group who may be adjusting without thorough diagnosis. Then again, the business model of The Joint … the chiropractic place, reported elsewhere in this Round-up, is also likely to be a target. The low costs services will also be likely to stimulate a limited commitment to differential diagnosis.

AOM’s certification organization

Notes from the 2010 annual report from the National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM)

The most recent Annual Report (2010) from the National Certification Commission for for Acupuncture and Oriental Medicine (NCCAOM) provides a useful glance inside the AOM profession. At the end of 2010, NCCAOM had 16,899 Diplomates worldwide, up 17% since early 2008. Operating revenues of the organization in 2010 were $2.9-million. Total applicants dropped from 1,833 in 2009 to 1481 in 2010. One part of NCCAOM’s mission is to provide “information and testimony” on various state licensing and scope issues to legislators nationwide. NCCAOM was active in 16 separate jurisdictions in 2010. The report concludes with a list of Professional Ethics and Disciplinary Cases that NCCAOM reviewed. NCCAOM chair is David Canzone, Dipl. Ac., DOM, Dipl. NBAO and the chief executive officer is Kory Ward-Cook, MT (ASCP), PhD, CAE.

Effort underway to revitalize National Association of Nurse Massage Therapists

A January 2012 release from the National Association of Nurse Massage Therapists (NANMT) announces efforts of the organization to revitalize its work under new leadership. According to the release, NANMT was organized in 1992 and “has been recognized as the official organization representing the specialty practice of Nurse Massage Therapy.” NANMT “supports the emerging trend of State Boards of Nursing to incorporate the specialty services provided by Nurse Massage Therapists as a component of the Nursing Process within the Scope of Practice of Professional Nursing.” The group is presently small. A national referral directory lists just 3 nurses massage therapists in Washington, 5 in California and 0 in Massachusetts. The membership standards are certification through the National Certification Board for Therapeutic Massage and Bodywork, licensing in a state as a massage therapist or completion of a 500 hour course.

Comment: As a sometimes patient, my bias is that more nursing professionals would be good at massage. It is pleasing to see that the massage education standard is not less than the already low standard (500 hours) for massage education. This is in contradistinction to the typically 150-300 hour of training typically required for a medical doctor, chiropractor or naturopathic doctor to be allowed to practice acupuncture under their MD, DC, or ND licenses – as compared to 10 times as many hours for a licensed acupuncture and Oriental medicine professional.

Supplier provides second million

Foot Levelers, major donor to chiropractic PR effort, pledges additional million dollars

The February 2012 issue of the newsletter of the Foundation for Chiropractic Progress (F4CP) announced that orthotics manufacturer Foot
Levelers has pledged an additional million dollars to support the profession’s robust public relations effort. The firm has already granted F4CP over $1.3-million since the organization was founded in 2003. As part of the new million, the firm matched $81,000 of pledges at a recent Parker Seminars meeting. These included, as the F4CP reports:

• American Chiropractic Association (ACA) increased its annual contribution of $4,000 to $8,000 (prior donations total $31,800)

• Michigan Association of Chiropractors made its annual pledge
  of $18,000 (prior donations total $57,000)
• Northwestern Health Sciences University contributed $14,000 (total contributions equal $102,500)
• Performance Health contributed $10,000, in addition to its
  normal $25,000 pledge, in honor of General Halstead’s service to chiropractic (total contributions equal $115,000)
• ChiroHealth USA contributed $2,500 in addition to its normal
  monthly pledge for 2012 (total contributions equal $26,205)
• Hill Laboratories became a contributor with a donation of
  $6,000 annually

Comment: This campaign is a textbook, profession-wide grassroots fundraising effort. The major contributors – Foot Levelers and Standard Process – are partially drawn in by the significant grassroots support. In this case, over 2000 individuals and organizations are making monthly contributions. In the driver’s seat as COO of F4CP is former ACA executive director Garret Cuneo.

Business

David Riley, MD

Global Advances in Health and Medicine, launched by veteran team, to focus on case reports

“Improving Healthcare Outcomes One Case at a Time.” So runs the title of the founding column from David Riley, MD, editor-in-chief of the new publishing venture entitled Global Advances in Health and Medicine.
The February 10, 2012 introduction of the
international journal adds that the editors “believe that high quality,
professional case reports will inform the design of clinical trials,
improve the quality of scientific information, and enhance healthcare
delivery.” (See announcement here.)

Riley, a long-time leader in integrative medicine, is the former editor of Explore and of Alternative Therapies in Health and Medicine. Two members of his former editorial teams, Jason Hao, DOM, and Michele Mittelman, RN, MPH, are part of the new international group, as is Greg Plotnikoff, MD, MTS, FACP. At the top of the list in the Information for Authors
of types of content that will be accepted for publication are “case reports, case series and case letters.” The release notes
that GAHM, LLC, the publisher, “building on the disruptive technologies
featured in the journal,” plans to eventually offer other publishing
and broadcasting products, conference and collaboration services and
“technology transfer and commercialization systems.” The GAHM Media Kit lays out how the team plans to reach over 90,000 practitioners globally. The MD/DO/PhD portion is 40% of the anticipated audience.

Comment: Riley, credited by
many for coining the phrase “integrative medicine,” is a veteran’s
veteran in this field. His work has included consulting on the minutiae of the Alternative Link coding system to helping
establish an integrative center in Dubai. I’ve had a chance to speak
informally with Riley and Mittelman about this project and am intrigued
with the ways they see technology adding power to case reports. It is
about time someone started a journal that has as its central focus what
actually takes place in integrative clinical practice. More on this venture as it
evolves.

Low cost chiropractic

The Joint … a chiropractic place: Massage Envy franchise model developed to offer low-cost adjustments

After selling the hugely successful Massage Envy firm in 2010, founder John Leonisio hit on the idea of rolling out a similar business model for chiropractic. He has done so as The Joint … the chiropractic place. The Joint members pay $49/month for which they can receive 4 chiropractic treatments. If members want additional visits, they pay $19 apiece. Non-members who walk-in off the street in this no-appointments environment pay $29 for an adjustment. An article in Arizona Business and Money form Leonesio’s home state reports that 146 franchises have already been awarded. These are open or under development in 17 states. Two St. Louis-based owners of Massage Envy franchises recently purchased rights as regional directors for The Joint for $145,000, according to this article.

Comment: There appears to be a good deal of excess capacity in all of the licensed “CAM” professions. The appearance of program that take advantage of the willingness of practitioners to work for less is not surprising. What dreams are some aspiring CAMpreneurs now having about how to use acupuncturists or naturopathic doctors in a similar model?

An early peer-reviewed publication in this space, Alternative Medicine Review, faces challenges


A personal appeal for subscription arrived recently from environmental medicine author-educator Walter Crinnion, ND to help save Alternative Medicine Review: A Journal of Clinical Therapeutics. The journal has been owned by Al and Kelly Czap, founders of Thorne Research

which they sold two years ago. The Czaps held onto the publication and
have been publishing it on their own, reportedly at a loss, since the sale. The
magazine was widely distributed for free to many practitioners and is presently
seeking to move to a subscription base at
$40/year. According to Crinnion’s note, the Czaps were targeting at least 2000 subscribers by early
March. Crinnion framed the potential termination of publication as “a
huge loss” for the naturopathic profession.

Comment: Al Czap has always ranked among
the more impetuous and influential characters in professional line supplement manufacturing for the evolving fields of
alternative, naturopathic and integrative medicine. Al Czap chose the company
name in the early 1980s as he wished to be a thorne in the side
of conventional treatment. If the business was to be a thorne, then this journal, which grew up with Thorne, was
perhaps the point of the spear. It gained PubMed searchable status early
with a mix led by NDs but including MDs, chiropractors and others
filling out the editorial team and advisory panel. Sun-setting is an honorable end-point. Perhaps the journal’s time has come.

People

Kara Kelly, MD

Kara Kelly, MD elected to presidency of Society for Integrative Oncology

Kara Kelly, MD is the new president of the Society for Integrative Oncology. Kelly is medical director of the
Integrative Therapies Program for Children with Cancer at the Herbert Irving
Child & Adolescent Oncology Center. Kelly also chairs both the integrative oncology committee and the Hodgkin lymphoma committees for the Children’s Oncology Group
(COG). She is an associate professor of clinical pediatrics at Columbia
University Medical Center and an attending physician at New
York-Presbyterian/Morgan Stanley Children’s Hospital and author or co-author of over 100 articles and
medical abstracts. According to an SIO newsletter, Kelly’s research in integrative oncology has “focused primarily on symptom
management during cancer therapy.”

Christine Goertz, DC, PhD

Christine Goertz, DC, PhD honored as Chiropractor of the Year

Christine Goertz, DC, PhD, was honored by the American Chiropractic Association as their chiropractor of the year. Integrator adviser Goertz presently serves as the sole licensed integrative practitioner on the Board of Governors of the Patient-Centered Outcomes Research Institute.
A decade ago, Goertz held a similarly pioneering position as the first
licensed “CAM” professional to be hired by the National Institutes of
Health as a program officer. Goertz day job is as vice-chancellor for
research and policy at Palmer College.

Roy Upton, RH (AHG)

Botanical resource from Roy Upton and the American Herbalist Pharmacopoeia honored by the American Botanical Council

In a February 28, 2012 release, the American Botanical Council (ABC) announced that the American Herbal Pharmacopoeia’s (AHP)
Botanical Pharmacognosy: Microscopic Characterization of Botanical Medicines (CRC Press, 2011), has been chosen as the 2012 recipient of ABC’s James A. Duke Excellence in Botanical
Literature Award in the reference and technical book category. The book’s production was led by senior editor Roy Upton, RH, DAyu, executive
director of AHP. Upton was supported by an international group of editors in developing Botanical Pharmacognosy, the introduction to which is available for download here.

Daniel Redwood, DC

Daniel Redwood, DC begins new health policy blog

Daniel Redwood, DC, considered “a gifted translator of complex ideas,” has initiated a health policy blog as Redwood HealthSpeak: Health Policy Perspectives. Redwood has held a series of roles as a go-between between his profession and other health policy players. His site boast testimonials, for instance, from James Gordon., MD and Marc Micozzi, MD, PhD. Redwood remains as editor-in-chief of Health Insights Today, a publication of Cleveland Chiropractic College where Redwood is a member of the faculty. Redwood was a co-editor of the recent report from the Integrated Healthcare Policy Consortium based on the September 2010 multidisciplinary conference of integrative health leaders called The
Affordable Care Act and Beyond: A Stakeholder Conference on Integrated
Healthcare Reform.

Would
you, as an integrative practitioner, guess that academic medical and other health
system-sponsored “integrative medicine clinics” reflect the typical,
community-based practice of integrative medicine?

Bravewell’s landmark 2012 report: But does it report what it claims?

Consider
the question differently: Do you think a consumer or policy maker would get an
appropriate sense of “integrative medicine in America” by examining what mainly
academic medicine-sponsored clinics provide?

A
fascinating new report suggests that you and the consumer should anticipate significant
equivalence. The intriguing and useful document is entitled Integrative Medicine in America: How Integrative Medicine is Being Practiced in Clinical Centers Across the United States. It is available to read or download
at www.bravewell.org.

This
beautifully crafted report, sponsored by the Bravewell Collaborative of
philanthropists in integrative medicine, is based on surveys and interviews.
They chose to limit the survey to a hand-picked set of 29 hospital-sponsored
and often academic health system-sponsored clinics.

This
is the face of integrative medicine that the Bravewell favors. This group of philanthropists
substantially founded and has backed for a decade the now 51 medical
school-member Consortium of Academic Health Centers for Integrative Medicine.

But
does the title mislead readers? Does the
report reflect the services consumers are likely to receive if they follow an
advertisement or website that draws them to your own “integrative medicine”
services?

The
authors explain their selection criteria for the 29 clinics on page 53, just
before the appendices, under “Challenges and Limitations”.

The centers
selected to be surveyed were those that provided an integrative model in which
conventional medicine plays an essential role. While these centers do, to some
extent, provide care drawn from other health systems – including naturopathy,
chiropractic, Traditional Chinese Medicine, Ayurveda, or homeopathy – centers
whose sole orientation is to deliver healthcare from these non-conventional
medical systems were excluded. The authors acknowledge that the responses may
have been different if another cohort of centers was surveyed.

The
language does not catch how narrow was the sample they chose to report. Left out
of the study set is the vast majority of what is being called “integrative
medicine” these days.

Not
included, for starters, is the lion’s share of the nearly 800 M.D. graduates of
the Fellowship in Integrative Medicine at the University of Arizona. What are
these graduates offering in their clinics and practices? Nor can this sample
include but a very tiny percentage of the 1500 M.D.s and D.O.s who are board certified
through the American Board of Integrative Holistic Medicine.

No
doubt, “conventional medicine plays an essential role” for these M.D. and D.O.s
who are Fellows in Integrative Medicine, Board Certified in Integrative
Holistic Medicine, or both.

And
how does an honest survey of “integrative medicine in America” not include the
medicine practiced by another set of some 3000 licensed physicians. There have practices
in which conventional pharmaceutical prescription authority is combined with
delivery of a broad array of “complementary and alternative” natural therapeutics.
This number is an estimate of the licensed naturopathic physicians (N.D.s) in
those states where they have gained broad pharmacy rights. For instance, here is the scope language on the Washington Association of Naturopathic Physicians site:

Naturopathic physicians (NDs) are trained to provide primary care
and/or naturopathic specialty care to patients of all ages. NDs see
patients with acute and chronic conditions and employ all standard
conventional diagnostic tools including physical examination, laboratory
tests, and imaging. NDs may utilize additional physical and laboratory
procedures to assess nutritional status, metabolic function, and/or
toxic load, while considerable time may also be spent assessing mental,
emotional, social and spiritual status to assure any treatment plan is
comprehensive.

NDs use a variety of therapies to promote health and treat disease
including: dietetics, therapeutic nutrition, botanical medicine,
physical medicine, naturopathic manipulative therapy, lifestyle
counseling, exercise therapy, homeopathy, psychological and family
counseling, and hydrotherapy. NDs can perform minor office procedures
appropriate to a primary care setting, administer vaccinations, and
prescribe most standard drugs when indicated. Like other primary
doctors, NDs delegate to nurses and medical assistants and refer to
specialists when appropriate.

This looks like “integrative medicine” – and is worth noting in part due to the numbers. The two sets of integrative MDs noted above total fewer than the number of NDs with a scope like this. Does this study
reflect the “integrative medicine” consumers receive from these N.D.s?

Then
there are the subsets of broad-scope chiropractors, functional medicine
doctors, advanced practices nurses and licensed acupuncture and Oriental
medicine practitioners who, while clearly outside the study’s scope, sometimes present
themselves in their communities as part of “integrative medicine in America.”

The financial energy behind the movement for IM in academic health centers

The
Bravewell report provides exceptional insight for anyone curious about health
system-sponsored integrative clinics. It fills huge gaps. One rifles through tables
of detail about the heretofore poorly-described phenomenon represented by these
clinics. One finds frequency of use charts for 34 separate therapies broken out
by 20 conditions. Another chart reports the types of practitioners likely to be
employed in these settings. Yet another shares the conditions for which the
authors found the least “differentiation of treatment.” Your guesses? The
former are “heart and hypertension” and “heart and diabetes”; the latter are
all acute pain related.

In
addition, business models are described. We see the chances that a given
service is paid via cash or through insurance. The authors explore “Core
Values”. For instance, how many of the clinics do you suppose agree that “we
use the least invasive and most natural remedies first”?

But
does one get what is promised in the title, Integrative
Medicine in America?

Enjoy this report on Integrative Medicine
in Health System-Sponsored Clinics in America. It’s a fascinating look into
a subset of mainstream medicine’s adaption to the consumer movement and
community-based practices that startled organized medicine nearly 2 decades
ago.

I invite
readers who practice “integrative medicine” or are familiar with
“integrative medicine” as offered in other venues to examine this study
and share whether it reflects community experience. Are
these aligned with your practice or care you have received? Do you think this report
reflects what it promises in the title?

Take a look and send any of your
thoughts about this study to
johnweeks@theintegratorblog.com. I’ll compile and
report back.

“You’re
either at the table or on the menu.” So runs the adage that defines much
in the Washington, DC Beltway.

Two early 2012 notices from
Len Wisneski, MD,
the chair of the Integrated
Healthcare Policy Consortium (IHPC), say a great deal about the relationship
between the integrative healthcare community and this power politics metaphor.
Wisneski’s first note described the opportunity of a life-time for the field.
The second announced just such a potential for the right mission-driven
individual. With a caveat.

Lead agent for the forum and for integrative practice in Washington, DC

Wisneski’s initial e-mail announced publication of IHPC’s long-awaited report
of a
Stakeholder
Conference on Integrated Healthcare Reform. The conference took place after
passage of the Affordable
Care Act (ACA).

If you believe that empowering health-focused, integrative approaches and
practitioners can make a difference in transforming U.S. health care, the
convening of this event was a beautiful thing to behold. After years of
significant but stuttering
accomplishment on a paltry budget, IHPC, the single, multi-disciplinary, collaborative,
torch-bearing lobbyist for integrative care in Washington, DC, appeared finally
to be ready to take a seat at the right tables.

The meeting was the brain-child of a power trio. One was Christine Goertz, DC,
PhD, vice chancellor at Palmer College. Goertz was since appointed to the
Board of
Governors of the Patient Centered Outcomes Research Institute. The second
was Janet Kahn, PhD, LMT, then IHPC’s executive director. Kahn was subsequently
appointed by President Obama to the Advisory
Group on Prevention, Health Promotion and Integrative and Public Health of
the National Prevention and Health Promotion Council. The third was Pamela Snider,
ND, IHPC’s vice chair, executive editor of the Foundations of Naturopathic
Medicine Project and past member of the Medicare
Coverage Advisory Committee.

Janet Kahn, PhD, LMT, IHPC’s key organizer for the meeting

Their plan was a no-brainer, but gutsy. Thanks to a group of U.S. Senators
including Tom Harkin (D-Iowa), Bernie Sanders (I-VT), Barbara Mikulski (D-MD),
Kent Conrad(D-ND) and Maria Cantwell (D-WA),
portions
of the 2010 Affordable Care Act (ACA) included integrative practitioners
and practices. The language was in sections related to payment, delivery,
research and workforce.

IHPC,
with its multiple stakeholder Partners for Health, and
the American Chiropractic Association, which Goertz sometimes advises, helped
place this language. These were firsts. A top-level policy summit was needed for the integrative health community to take
maximum advantage of the new law. The three set a date for late September 2010,
and a place, at Georgetown University.

The gutsy part was finding the cash to convene. Goertz’ brought in her base, Palmer College, and as a financial host. Brian
Berman, MD committed the The Institute for
Integrative Health (TIIH). Berman, who also directs the Center for Integrative Medicine
at the University of Maryland is a former Bravewell
prize winner. He and one of his TIIH co-founders, Aviad (Adi) Haramati,
PhD, were the founding chair and vice-chair, respectively, of the Consortium of Academic Health Centers for
Integrative Medicine (CAHCIM). CAHCIM, with its 51 medical school members,
is the biggest kid on the integrative medicine block. Bastyr University’s

Center for Policy and Leadership also stepped in with funding as did Hyland
Laboratories, led by policy wonk Jay Borneman,
MPH, PhD.

Christine Goertz, DC, PhD: part of the power trio

The
leadership mix ran from integrative MDs, across the CAM disciplines, with a
touch of industry funding to remind us that this is U.S. medicine, after all.

The relationships between these professionals, like many of the 60 individuals
they convened, run deep. A significant subset convened the
National Policy Dialogue to Advance
Integrated Health Care: Finding Common Ground in 2001. Berman and
Kahn are presently members of the National
Advisory Council of the National Center for Complementary and Alternative
Medicine (NCCAM). Snider had a significant role in shaping NCCAM’s enabling
language. Goertz formerly worked at NCCAM as a program officer.

Among participants were U.S. Senate staffers, a former state insurance commissioner, policy
leaders from the licensed integrative practice disciplines of chiropractic,
naturopathic medicine, massage therapy, certified professional midwives and
acupuncture and Oriental medicine. I was invited as a representative of the
Academic Consortium for Complementary and Alternative
Health Care. Others included Lori Knutson, RN, BC-HN, then executive
director for the integrative
health program at Allina Hospitals & Clinics, created by philanthropists
Penny
and Bill George. Another was Wayne Jonas, MD, CEO of the Samueli Institute, credited with conceiving the whole systems structure
of the National Prevention Council. The participant list is on page 51 of the document.

Integrative health care had never seen such band-width. The report, entitled
The
Affordable Care Act and Beyond: A Stakeholder Conference on Integrated
Healthcare Reform, reflects it. The editors are Daniel Redwood, DC, Michael
Traub, ND, DHANP, and Kahn. Snider oversaw final publication.

Pamela Snider, ND: The 3rd in the organizing trio

The document’s heart is a series of recommendations from each of 6,
well-integrated work groups: Access and Non-Discrimination; Integration in
Practice; Comparative Effectiveness Research and the Patient-Centered Outcomes
Research Institute; The Healthcare Workforce Prevention and Wellness; and,
Current Procedural Technology (CPT) Codes.

The
work wasn’t blue sky. All but one of the work groups was linked to a relevant portion
of the Affordable Care Act (ACA). The outlier, CPT, included two members of
the American Medical Association’s advisory panel.

Jonas, who headed the NIH Office of Alternative Medicine in the mid-1990s,
offers this appraisal: “The IHPC policy report is the product of one of
the most collaborative, multi-stakeholder processes in the entire integrative
medicine industry. It should be carefully attended to by practitioners and
policy makers alike.”

All good, so far. But why wasn’t the report published a year ago? Why hasn’t it
been available to guide active participation at a half dozen federal agencies?

The
question brings us to the second of IHPC chair Wisneski’s notices and the Achilles
heel for integrative health policy work. The field has not yet chosen to step
and fund necessary lobbying. With Kahn’s leadership, IHPC engaged some of the
regulatory relationship-building recommended. Some CPT
coding
language was changed. Key appointments were recommended, among those the positions
presently held by Goertz and Kahn.

But IHPC funds were drying up. The report was
back-burnered for months. Kahn, after a half-dozen years of underpaid, Sisyphean work,
decided to leave IHPC’s directorship and move to an essentially volunteer national
policy adviser role.

I’ve
observed IHPC for a decade. It typically finds a way, if long on mission and
short on fuel. Wisneski’s note indicated that IHPC had cobbled together the
funds to advertise for a new director, half-time to start. Interested?

Help wanted. Wisneski calls it “the opportunity of lifetime, for the right
person.” The caveat is that this someone must enjoy an ancient method of community organizing:
grow the organization, advance the mission, increase the funding base, grow
your salary and staff; move the stakeholder agenda.

Help is definitely needed. If integrative medicine is to transform itself from
a
puer aeternis
into a responsible participant in shaping U.S. policy, this strategic plan under
the Affordable Care Act needs contributors, more Partners for Health, and
deeper pockets. The blueprint is there. The table is set. More individuals and
organizations must chip in.

Where
are the philanthropic agents of change who will forgo the charitable deduction
because moving this work, in this moment, can be a great deal of fun and a tremendous legacy?

It’s not clear the extent to which the integrative health field will step up to the opportunities in this
IHPC report. If yes, the nation’s potential for a health focused policy will move toward the top
of the agenda rather be on the menu.

Policy

Family doctors challenge AMA specialists control of Medicare fees

AMA’s Influence on Payment Attacked in Court, Congress

Under a two-decade old relationship, a panel dominated by
tertiary-care-based specialty societies of the American Medical Association has
met behind closed doors to set fee structures which, over 90% of the time,
guide reimbursement policies of the US government. AMA’s
Relative Value Scale Update Committee, known as the RUC, is a 29-member panel
of representatives from MD medical specialties. RUC determines the relative value
of specific medical services then makes recommendations to the Center for Medicare and Medicaid Services (CMS). CMS typically
rubber stamps these over 90% of the time. Now a group of primary care physicians based in
Atlanta, Georgia is suing the US government to end the practice and make the
advisory group a US panel that will operate with transparency.

McDermott: Legislation to curb RUC

The suit is supported by Congressman Jim McDermott (D-WA).
McDermott, a psychiatrist, has independently introduced legislation that, while
it would not strip the RUC away from the AMA, would create more balance in its
membership and openness in its processes. McDermott told Medpage that he
supports efforts, whether judicial or legislative that seek to limit the
influence of high-end specialties on rate-setting at the Centers for Medicare
and Medicaid Services. On March 30, McDermott posted on his website that “for two decades now, this panel has been dominated
by specialists who undervalue the essential and complex work of primary care
providers and cognitive specialists, while often favoring unnecessarily
complex, costly and excessive specialty medical services,” said McDermott
in a statement posted on his website in March 2011. The American Academy
of Family Physicians supports the McDermott legislative, which is entitled the Medicare
Physician Payment Transparency and Assessment Act of 2011 (H.R. 1256). 

The Atlanta doctors argue in their August 5, 2011 posting on
their webpage, that the relationship between the RUC and CMS
“creates systemic incentives to provide unnecessary and unnecessarily
complex services.” They add that “it is not unreasonable to argue
that this single relationship is the core driver of runaway healthcare costs,
threatening the stability of American healthcare economy and the larger U.S.
economy.” The doctors are also collecting donations for the lawsuit
through the site.

Comment: I agree
that the power of the specialists as expressed through RUC is a huge barrier to
change. Any honest SWAT analysis, or treatment plan, would identify the RUC diversion of resource and target a plan to remove this obstacle to cure. Good for these Atlanta
doctors and for McDermott. Each of the integrative practice fields should file amicus briefs, in they haven’t already.

Paulus: Integrative medicine an asset in ACOs

Accountable Care Organization CEO calls integrative medicine a financial asset in Obamacare model

“For the first time ever, the payment
will change toward keeping people healthy … For the first time in 100
years it will be our job at
Allina to keep the village healthy.” So spoke Ken Paulus, CEO of
Minnesota’s huge Allina Hospitals & Clinics at the November 10, 2011 Integrative Medicine in Action event hosted by the Bravewell Collaborative. This shift, Paulus
believes, will be “the point of inflection” for
integrative medicine. He is quoted in this Huffington Post article:

“When I first heard of integrative medicine,  I saw you as an expense.
But [as payment in Accountable Care Organization (ACO) structures] kicks in
that
supports keeping people healthy, you will be an asset. Integrative
medicine
will be an asset.”

Paulus did not describe the exact details of how ACOs will support this shift. Instead he referenced the story of Chinese barefoot
doctors who were only paid by communities if the people in their
charge were kept healthy. Paulus positioned integrative approaches as
aides in such health creation.

Comment: I had the opportunity to hear
Paulus’ comments and felt a certain giddiness that may only be
explained as the promised resolution of unrequited desire for economic alignment for integrative medicine.
Capitalism in US medicine tends toward the big margins of what might be
called SUV medicine: inpatient services, patented drugs and high-tech
machines. Paulus suggested that the ACOs established by the Obama-Pelosi
reform are creating a context for developing what some of us 10 years ago dubbed “a thriving industry of health creation.” This provoked a re-publication of the Design Principles for Healthcare Renewal for which this phrase was crafted as part of Principle #9.

Patient-Centered Medical Home leaders Zunin and Trompeter see exceptional opportunities for integrative
teams

In preparation with integrative pediatrician Larry Rosen, MD for a February 11, 2012 presentation on ACOs, PCMHs and integrative medicine at the Integrative Healthcare Symposium,
I recently interviewed two integrative health leaders with emerging
patient-centered medical homes (PCMHs). The topic: How do they see they see the potential fit with
integrative health approaches? Tom Trompeter, MHA, is CEO of Healthpoint,
a network of 10 federally-qualified health centers in the Seattle-area.
For 15 years, these centers have integrated services of naturopathic
physicians, licensed acupuncturists and massage therapists with
their PhD psychologists, nutritionists, dentists and MD/RN staff. Trompeter
speaks of the PCMH, which he prefers to call a “health home,” as a
“break from the paradigm of a physician owning a patient.” Similarly: “It’s not about the billable visit.” The concept of patient ownership shifts, in Trompeter’s view: “My patient needs to transition to our patient.” He believes this opens the door to teams and “the team approach opens the door for diversity” of providers and services. The Trompeter interview is here.

Ira Zunin, MD, MPH: Contracting as a PCMH

Integrative physician Ira Zunin, MD, MPH, MBA is the founder of the 40 practitioner Manakai O Malama center
in Honolulu. Zunin’s clinic was approached by leaders of the local
delivery system to merge his center with the area hospital and payers
through linked electronic medical records (EMR). Zunin describes
significant immediate value via increase in referrals that the EMR
created for his acupuncturists, massage therapists and naturopathic
doctor. He underscores Trompeter’s point
on payment: “In the PCMH, payment plays into our hand. You have
unassigned dollars that aren’t directly connected to a
provider or a procedure or a code. You can use the dollars from an
integrative perspective.”  In this Integrator interview, Zunin speak also to the significant challenges. Yet his overall view is positive: “The PCMH model is supposed to help the whole person, in his or her
community. We’ve always been looking at everything with a bigger tool set, with
a focus on health. We’re oriented to this model. We’re oriented to teams.” 

Comment: Since these interviews, I found myself listening to a local practitioner bemoaning the awkward fit of the insurance coding dance for a whole person practice that is relationship-based, time-intensive and individualized. I was pleased to say: You might check in with the leaders of the local ACO movement to see if you can get paid to keep people healthy. Their may be light at the end of integrative medicine’s economic tunnel. 

Berwick: Friend of IM leaves CMS

Integrative medicine loses a friend in a high place as Berwick gets “pink slip” from Republicans

Comment: Healthcare writer Joe Nocera caught up with Donald Berwick, MD within a week of Berwick’s exit from his recess
appointment as administrator of the Centers for Medicare and Medicaid
Services (CMS). In his December 5, 2011 New York Times op-ed piece (Berwick’s Pink Slip) Nocera writes: “Dr.
Berwick, I’m here to tell you, was the most qualified person in the
country to run Medicare at this critical juncture, and the fact that he
is no longer in the job is the country’s loss.” I agree. The fact that Berwick
once spoke favorably about the British health system model that costs
half as much as that in the US and produces better outcomes sealed his fate before his Republican executioners. Berwick’s
extension of evidence-based medicine to evidence-based policy-making is apparently as palatable to medical business-as-usual as is the science behind global
warming for Big Oil. The waste-trough of US medicine, estimated by leaders at the
Institute of Medicine to be at 50% of the $2.6-trillion spent annually, seems to have only produced compelling evidence of a donor base, not scientific base, for the Republicans who pushed him out. 

IOM report with Berwick’s IM principles

Meantime, when Berwick stepped down, integrative medicine lost a friend in a high place. As noted here, Berwick’s positive perspective on integrative
medicine is on record. He was a keynoter at the February 2009 IOM
Summit on Integrative Medicine and the Health of the Public. Berwick elucidated his “Basic Principles for Integrative Medicine.” They are worth restating here on his exit.

1. Place the patient at the center.
2. Individualize care.
3. Welcome family and loved ones.
4. Maximize healing influences within
   care.
5. Maximize healing influences outside
   of care.
6. Rely on sophisticated, disciplined
   evidence.
7. Use all relevant capacities – waste
   nothing.
8. Connect helping influences with
   each other.

This is a
pretty darned good list to
hang on the mirror as a daily reminder for those in the field of integrative health. Now, let’s
see what Berwick, the founder of the Institute
for Healthcare Improvement (IHI) will be up to next.

Integrative Centers

Horowitz: Union leader organizes CAM in medical home

Freelancers Union’s insurance company to innovate alternative care in patient-centered medical home

The Freelancers Insurance Company (FIC) is pioneering strategies to bring alternative care into a patient–centered medical home, according to an article, Health Care for a Changing Work Force, in the December 1, 2011 New York Times. FIC reportedly has revenues of roughly $100 million
and covers 25,000 independent workers.  Because FIC maintains a close relationship with its insureds, “it can be
more effective [than most plans] helping its members make good health care decisions.” Sara Horowitz, the founder of the
Freelancers Union, which owns FIC, explains:
“We’re moving away from fee-for-service medicine to one where a primary
care doctor aggressively coordinates care … We’re
also trying to innovate with alternative care — promoting meditation,
yoga, and nutrition which can have long-term beneficial effects.” The article notes that in
2012, the organization will be opening up the Brooklyn Freelancers
Medical Practice. This center will be a patient centered medical home (PCMH) based on the model of Rushika Fernandopulle, MD who “pioneered a team-based model of care that is attracting attention across the country.” The FIC’s
rates are already a third below market. (Thanks to Integrator adviser Glenn Sabin for the link to this article.)

Waller: Big ER savings anticipated from integrative center

Grand Rapids ER’s new “Center for Integrative Medicine” anticipated to save system over $10-million each year

A new strategy for emergency room services based on a close partnership
with an integrative medicine center is expected to save upwards of $300
million a year when expanded to 8 hospitals. In an MP3 available interview, Corey Waller, MD explains that the person-centered, time-intensive approach that will be mounted in Grand Rapids, Michigan focused on high-utilizers. Waller’s team identified 953 people in the system who accounted for 20,000 visits in 2007-2011. A pilot study of just 30 patients
found ER services could be reduced visits by 85% for each participant
for a savings of $1-million. The intensive treatment at the integrative medicine center begins with a 4
hour visit. This includes an hour each with an MD, a nurse case worker, an MSW for
psychiatric and substance-related diagnosis and then a “regular social worker” and office staff who focus on community support issues. Patients are being recruited to the center by directly calling those who used the ER 10
or more times in the previous year. The program is expected to cost $950,000 a
year but is expected to save the ER $3.5 million and also reduce costs by some $25-$35 million for the two feeder hospitals. Spectrum health’s news release is here.

Comment: My first feeling on listening
to the MP3 regarded the horror of current practices. How can we have drifted to a point where such huge savings are ostensibly such low-hanging if we just organize some caring contact? Why are we only getting on this now? 

I also find it interesting and even ironic
that Spectrum chose to call their new clinic a “center for integrative
medicine.” While the program is patently “integrative,” no one associated appears to have any direct relationship to what may be called the movement for integrative medicine. The re-frame brings to mind the way
that Christy Mack, head of the Bravewell Collaborative, pointedly declares that “integrative medicine is not CAM.” Now the Spectrum group
appears to be declaring that integrative medicine is not integrative
medicine. The Spectrum version is a bio-psycho-social-environmental team-based approach with no apparent connection with the integrative medicine in academic
medicine field, such as Mack and Bravewell have backed. Nor does the Spectrum model reflect
services advanced in the holistic medical community, or in the CAM
disciplines. One way to look at this is to simply declare success. That said, it would be interesting to see how integrative medicine and CAM leaders might add value to this already remarkable integrative medicine
initiative.

Partnering for integrative services for employees

Arizona Center for Integrative Medicine partners with
Maricopa County to pilot test integrative primary care clinic

According to a November 28, 2011 release,
the University of Arizona
Center for Integrative Medicine (AzCIM) has engaged a partnership with
Maricopa County, Arizona [Phoenix] to pilot delivery of integrative medicine to
the county’s 13,000 public employees. Medical outcomes and costs will be compared between patients receiving
conventional medical care and those receiving integrative care. The Adolph Coors Foundation funded the pilot, which is expected to generate publishable data on the effect of integrative medicine on patients’ health.

Arizona Centers Weil and Victoria Maizes: Testing integrative clinical model

The Phoenix Integrative Primary Care
Clinic is slated to open in July
2012. Says Andrew Weil, MD, founder of the Arizona Center: “We
believe this is the first step toward changing priorities of
reimbursement, away from disease management and dependence on costly
pharmaceutical drugs and other high-tech interventions, and toward
sustainable wellness,” said Andrew Weil, MD. Roughly 1500 employees are expected to access services the first year. David Smith, Maricopa County manager explains the county’s interest this way: “Given
the current health-care cost spiral and obesity crisis in the United
States, the Maricopa County Board of Supervisors has decided to make
preventive integrative care and treatment options more accessible to our
employees.” Initial information on the
program does not specify what sort of integrative services would be
offered. A useful article on the project is here. A PDF of the agreement between the two entities is here.

Comment: The program, while certainly not the “first step toward changing priorities of reimbursement,” is an interesting
and perhaps even high-risk gambit for the University of Arizona Center.
The Center is not known for the clinical components of its
training. It’s signature fellowship is principally online. What will an “integrative medicine intervention” include? What
population(s) will the clinic target? A smart move might be to emulate the
Spectrum Health program, reported above, and bring in those high utilizers.

Karan: Urban Zen originator goes bi-coastal

Donna Karan brings Urban Zen Integrative Therapy program to UCLA

The New York-based Urban Zen Integrative Therapy Program is now officially bi-coastal. The Donna Karan backed program announced on November 18, 2011 that it is partnering with UCLA. A first group of 30 doctors, nurses and other allied health professionals began training in September. Gillian Cilibrasi, Urban Zen’s program director explains: “During
this curriculum, medical professionals from the UCLA Health System (are) trained in five modalities of treatment: yoga therapy, Reiki,
essential oil therapy, nutrition and contemplative care.” In comments contained in the release, David Feinberg, MD, MBA, president of the UCLA Health System, positions the Karan initiative as advancing UCLA’s long-time commitment to integrative approaches. Referenced were the UCLA Center for East-West Medicine and UCLA‘s Mindful Awareness Research Center. The Ronald Reagan UCLA Medical Center, part of the UCLA Health System, is
the first UCLA hospital and the first on the West Coast to adopt the Urban Zen program.

Comment: I confess to wondering when I first heard about Urban Zen’s go-it-alone expansion plans. Hollywood is clearly the next best place to leverage Karan’s name and involvement to secure the additional philanthropic support that UCLA has already announced that it will be seeking. 

Business of Integrative Medicine

Rober Jahnke, OMD: update on diverse initiatives

Update from Roger Jahnke, OMD: Advancing the understanding, science and adoption of Qigong and Tai chi

An early leader in integrative health is author, consultant, organizer and teacher Roger Jahnke, OMD. Jahnke has a list of organizations
with which he as consulted over the past 15 years that is as long as
your arm. He contacted me recently on what was being done, if
anything, with the Design Principles for Healthcare Renewal.
He and I were involved in developing these in 2001.

The contact provided a chance to catch up with Jahnke. The co-founder and past chair of the National Qigong association recently keynoted Mindbody Week in Washington, DC with Herbert Benson, MD. A year ago, Jahnke was lead author for A Comprehensive Review of Qigong and Tai Chi published in the influential American Journal of Health Promotion. With that foundation, the author of The Healer Within

and other books is presently involved in training staff at the
Veteran’s Administration on the values of Qigong and Tai chi. Jahnke and his group also recently completed a Phase 1 SBIR trial
with NIH National Center for Complementary and Alternative Medicine. He reports “excellent results.” They are preparing a Phase 2 submission. Meantime, via his own Institute for Integral Qigong and Tai Chi Jahnke has surpassed 1000 in the total number of “teachers and practice leaders” trained. Jahnke began offering the program in the 1980s. It was an early venture into the health and wellness space and has been used by diverse military, health system and health promotion clients since.

Comment: The challenges in finding business
models for integrative medicine have swallowed many a sailor. That
Jahnke has persevered is testament to the broad set of
skills and abilities he brings to diverse integrative health stakeholders.
Jahnke has one of the more interesting resumes of survivors. He wrote: “I remain inspired by the ‘principles’, when do you think you will resurrect?
Would be honored to participate.” Below is a minor resurrection. It’s timely, for reasons I note.

Commissioners were presented the Design Principles in 2001 exploration of CAM policy

10 Years After: “Design Principles for Healthcare Renewal” Resonate for Integrative Medicine’s Future

Recently long-time
integrative health author, system-consultant and pioneer Roger Jahnke,
OMD urged me to “resurrect” a document from the early years of
integrative health that we called the Design Principles for Healthcare Renewal.
I realized on considering this that it
is almost exactly a decade since these were well-received in October
2001 as a clarifying document by the members of the White House Commission on Complementary and Alternative Medicine Policy. Jahnke’s
request also resonated with a presentation at the Bravewell Integrative Medicine in Action event November 10, 2011. There Allina CEO Ken Paulus (see above) suggested that the US might finally be on the verge of an economic
incentive structure to support a “thriving industry of health creation”
(Principle #9). Those 10
principles, borne out of a Task Force on Principles from the 2000 Integrative Medicine Industry Leadership Summit are reprinted in this article.

Comment: Do these have useful
resonance for you? I view 3 sections as particularly potent, yet under-expressed in
the evolution of integrative medicine since 2001. These are the concepts of the
“hierarchy of treatment” (#4), the respect for the “fullness of diverse
health care systems” (#5) and then, the principle that stimulated this
re-publication, the need to stimulate development of a “thriving industry of health
creation” (#9). The Obama-Pelosi health reform appears to be a boost to the latter. Is there yet more
value in “resurrecting” these principles further? 

Academic Health Care

Robust IPE/C conference draws nearly 800

Why complementary and integrative medicine stakeholders should piggy-back on the interprofessional education/care movement

Roughly 750 professionals and clinicians involved in
interprofessional education and care (IPE/C)  attended the 3rd biennial Collaboration Across Borders conference
in Tucson, November 19-21, 2011. The robust gathering, double the size of previous events, was
described as a point of arrival for interprofessional education by the leaders of the movement. Team-care focused health professions education has a stronger
foot-hold in Canada than in the United States. Speaker
David Moen, MD, president of a 1300 physician Fairview Physician Associates

told attendees that the value of interprofessional teams in US healthcare is advancing
dramatically under changes in payment stimulated by Obama’s Affordable Care
Act. These include payments related to patient satisfaction, limiting re-admission
rates and lowering of tertiary care costs. Enhanced teamwork is
anticipated to help produce these financial benefits. This in turn is expected to stimulate
investment in IPE/C. Moen and others view this shift toward teams as a “culture
change” throughout academic medicine and delivery.

Comment: IPE/C was first advanced in US medicine via the community
clinic movement in the late 1960s and early 1970s. The field failed to gain
traction as costs, waste and errors increased under a specialist-dominated
system. The present rebirth of IPE/C followed the 1999 publication of To Err is Human by the Institute of
Medicine. The report found that medicine kills over 100,000 a year, ranking it
among the nation’s major killers. Subsequent analysis, published by the IOM in 2001 as Crossing the Quality Chasm, indicated that the most significant factor in medical errors is
the lack of communication, understanding and mutual respect among doctors,
nurses and other professions.

Moen: Obamacare incentives promote team care and IPE

The
parallel perspectives of Moen, regarding IPE/C’s re-emergence, and those of
Allina leader Paulus, noted above, relative to the more positive horizon for
integrative medicine, are striking. The changed payment structure under the
Obama reform is opening interest in both IPE/C and integrative medicine. Enhancing
teamwork is core to IPE/C and sometimes central to the integrative medicine effort. Colleagues in the Academic Consortium for Complementary and Alternative Health Care
(ACCAHC) organized a donor-backed campaign that stimulated roughly a dozen representatives
from educational institutions in these disciplines to attend the conference. This multi-disciplinary, allied-health-dominated community was quite
receptive to integrative health ideas and disciplines. While the academic integrative medicine
community was not well-represented in this conference, success of
integrative medicine may be closely linked to IPE/C even as each appears to be linked to the shifting financial
incentives under Obamacare.

The Collaboration Across the Borders IV meeting will be in
Vancouver, BC in 2014.  Another
significant IPE/C conference will take place May 18-19, 2012 at Jefferson University
entitled “Interprofessional Care for the 21st Century: Redefining Education and
Practice.”

PCOM: First nursing program in CAM school

Pacific College of Oriental Medicine announces new holistic nursing program

Pacific
College of Oriental Medicine (PCOM) announced on November 30, 2012 that it will begin offering a unique holistic
nursing Bachelor of Science Completion Program in Holistic Nursing through its
New York Campus. This is the first bachelor degree
nursing program within a CAM school in the country.  The program was developed in consultation
with Carla Mariano, EdD, RN, AHN-BC, FAAIM, who also initiated the
holistic nurse practitioner program at New York University and is past-president
of the American Holistic Nurses Association.  Mariano told the Integrator that the
program is particularly timely as the nursing profession has a growing
commitment to establish a bachelors’ level as the basic educational standard for professional nursing. “BSN in 10” refers to the pending legislation requiring associate degree registered
nurses to obtain the baccalaureate degree in nursing within 10 years of initial
licensure. The states of New York
and New Jersey each have legislation promoting this change. This direction for
the nursing field was propelled by the October 2010
Future of Nursing

report from the Institute of Medicine and Robert Wood Johnson Foundation.

Mariano: Key adviser on PCOM project

Mariano, an Integrator adviser, notes other features of the PCOM program that are
expected to draw nurses: “Integrative holistic
health care is becoming more mainstream and nurses are increasingly
focused the whole person and holism as a practice framework. PCOM nursing
students will be prepared in holistic theory and therapies for health, healing,
and wellness as well as leadership, community, and research.” She
thinks that “a nursing program in a CAM school” will be attractive
for the “interdisciplinary nature of the learning
environment.” Students from acupuncture, massage,
and nursing programs will share a number of required
and elective courses. In addition, the nursing students are expected to
have the opportunity to participate in various PCOM community health and health
promotion programs.

Comment: This is a smart, intriguing
link for PCOM, an entrepreneurial, for-profit AOM school. It will be
interesting to see how this model of integrated education matures.

Stewart: First ND in Arizona elective

First naturopathic student participates in month-long integrative medicine elective at Weil’s Arizona program

A November e-bulletin
from the Association of Accredited Naturopathic Medical Colleges notes
that earlier this year Adrienne Stewart became the first naturopathic medical
student selected to participate in the month-long elective rotation in
integrative medicine at the Arizona Center for Integrative Medicine. Stewart, now a naturopathic physician graduate from the Southwest College of Naturopathic Medicine (SCNM), jointed a group of MD students and residents from across the United States. A brief note in the SCNM news states:

“Dr. Stewart finished this rotation with a great sense of community
and gratitude. As the first
naturopathic physician to attend this rotation, she recognizes the need for naturopathic
physicians to be involved in the discussion of integrative medicine. She says, ‘Making positive changes from the
current health paradigm requires one of our greatest principles-docere. Docere not only involves the doctor and
patient relationship, but also extends to doctors as educators throughout our
evolving healthcare system.'”

Comment: Kudos to the
Az Center for opening the door and to Stewart for walking through. My guess is that the
interprofessional component of this educational experience may have been
as rich for both Stewart and her conventional classmates as were any of
the courses.

Professions

Forbes: Time for integrative MDs to get certified

Holistic leader Forbes and ABIHM on grandfathering plans for the Arizona Center’s new Board Certification in Integrative Medicine

“The proposed merging process, we anticipate, will include ‘grandfathering’ of current ABIHM diplomates, making
the value of becoming certified over this next year a highly valuable
proposition that any interested physician (MDs and DOs) should strongly
consider. Now is the time!” So writes David Forbes, MD, ABIHM, past president of the American Holistic Medical Association (AHMA) in the recent issue of AHMA’s newsletter. The italics are his. He expands: “Movement is occurring to merge interests with the Arizona Center for
Integrative Medicine in an endeavor to further hone an Integrative
Medicine Board Exam and increase the clout and credentials that such
certification would bring.” Forbes concludes by underscoring  the potential future value of the getting certified through the American Board of Integrative Holistic Medicine (ABIHM) today: “If you are not certified

yet by ABIHM, I urge you to do it next year! It is a deeply valuable
experience, an unparalleled exposure to the best of holistic/integrative
education, and a credential that is only going to exponentially
increase in value over the coming years.”

Supporting new Arizona-backed initiative

The web-page of the ABIHM makes it clear that the ABIHM is fully backing the University of Arizona-led effort to create a more formal board certification in integrative medicine through a relationship with the American Board of Physician Specialties (ABPS). Grandfathering appears to be understood: “At this time, it appears that ABIHM Diplomates whose status is current
will be forgiven the fellowship requirement for sitting for the [new]
exam. All ABIHM Diplomates who wish to become certified by the ABPS will
be required to sit for the new exam.”

Comment: It’s a foolish medical doctor with any interest in integrative medicine who will not get moving on getting the ABIHM certification if he or she hasn’t got it already. “Forgiving the fellowship” forgives a $30,000 tuition fee, plus a significant time commitment.

Gaudet: Book for OB-Gyns re-published

OBGyns re-publish CAM booklet written by Tracy Gaudet, MD

The October 2011 edition of Clinical Updates Women’s Health Care from the American College of Obstetricians and Gynecologists is entitled Complementary and Alternative Medicine.
The author is Tracy Gaudet, MD, former director of integrative medicine
programs at the University of Arizona and at Duke University. The
98-page monograph was first published in 2004. The intent is stated in
the abstract: ” … to help (OBGyns) guide patients in their treatment
choices, including guiding them away from potentially dangerous
alternative treatments and supporting their use of potentially
beneficial treatments.” Herb-drug negative interactions are highlighted early. Figure 1 provides readers a helpful “protocol for integrating complementary and alternative medicine with conventional medicine.” Page
78 offers a 16 question exam that can be taken to gain CME credit.
Chiropractors will not be pleased to see that the very first question
asks about “the most significant risk” from their services.

Battle between licensed acupuncturists and “dry-needling” escalates

Portland, Oregon-based Marilyn Walkey, MD, LAc is a rare medical doctor who has also
completed discipline-level training in acupuncture and Oriental
medicine (AOM) and gained licensing in that field. Walkey is not a fan of medical doctors or other practitioners who take short courses to practice “dry-needling” or other techniques that appear to the common person to be acupuncture. On November 25, 2011, she sent a link which she editorialized in an e-mail was “wonderful news from Medicare regarding ‘dry-needling.'” The document noted that one Mark Bucksbaum, MD from the Center for Integrative Medicine in Rutland, Vermont had paid $35,000 to settle with Medicare. The reason: Bucksbaum billed the federal agency for “trigger point injections” when these were actually “dry needling,” according to assistant US attorney Kevin Doyle. Doyle said that the only legitimate way to bill for such services was to use acupuncture codes, which are not covered by Medicare. 

Meantime, across the country, in Walkey’s homestate of Oregon, the Oregon Association of Acupuncture and Oriental Medicine received a supportive finding in its suit against the state’s Board of Chiropractic Examiners and the University of Western States, which is principally a chiropractic school. The acupuncture association argues that “dry needling” as practiced by chiropractors is “substantially the same” as acupuncture, and therefore should be illegal. Walkey sent notice in mid-November that the judge has found the OAAOM had a “likelihood of winning on merits.”

Comment: Inside the multidisciplinary Academic Consortium for Complementary and Alternative Health Care (ACCAHC) we call these these guild-battles “hotspots.” They come up a lot. One field’s expansion of practice by adding a modality threatens another’s basic practice. AOM practitioners may add Western herbs or homeopathy to their score with no additional required education. These cross over into the naturopathic doctor’s core training. Or to reverse the situation AOM-DC battle over needles, the AOM practitioner may use limited training in Tuina to effectively cause spinal adjustment but without education in chiropractic manipulation. Similarly, naturopathic doctors practice spinal manipulation based on far fewer hours than chiropractors. And NDs have the right to practice acupuncture in some states, as many states chiropractors and medical doctors do, based on 200-300 or fewer hours of education. Virtually all licensed integrative practitioners can give massage, regardless of whether their training touches even a 500 hour basic massage curriculum. Meantime, integrative medical doctors piece together practices through a series of weekend or multi-weekend courses, that rarely come close to matching the educational background of naturopathic doctors. At the same time, NDs and DCs claim rights as “primary care doctors” without completing post-graduate residencies. 

We in ACCAHC have attempted to find “cooling places” for the “hotspots.” What are the principles that might guide educators through this mine-field of guild sniping and bombing?

Our ACCAHC discussions (we have no position statement) have suggested that all disciplines make significant distinctions between modality-level education and discipline level education. Educators in any discipline that adds therapies through “modality level” training (such as acupuncture for pain) would optimally be required to make a point of thoroughly educating students to the substantially higher standards of those who have completed discipline-level training. Example: the licensed acupuncture and Oriental medicine practitioner. Then there is the basic Pew Commission koan, as my colleague and ACCAHC co-founder Pamela Snider, ND learned through an examination of the naturopathic profession by the UCSF Center on Health Professions: Training to tested competency to scope. Something tells me that the acupuncturist versus dry needling battle will persist for some time regardless of any reasonable cooling points.

Madigan Medical Center: Hiring LAcs

Acupuncturist job listing for the Army puts salary at $73,000-$95,000

In mid-November a federal government jobs listing asked for two licensed acupuncturists for the Army Madigan Medical
Center, joint Base Lewis-McChord outside Tacoma, Washington. The listing is for a salary range of $73,4200-$95,444 per year. The two professionals will be part of the Interdisciplinary Pain Management Center. The Center is described as:

” … focus(ing) on pain management strategies that are holistic,
multidisciplinary, and put Soldiers quality of life first. As a licensed
Acupuncturist, you will offer a full array of current and emerging
evidenced-based approaches for patients with acute and chronic pain who have
not responded well to conventional treatment modalities. You will work within a
multidisciplinary team to provide assessment, planning, implementation,
coordination, evaluation, and monitoring of patients for health options and
services. You will assist in developing, analyzing, integrating, monitoring,
and managing healthcare delivery systems through communication and use of
resources to promote quality and cost-effective outcomes across the continuum.”

Comment: We are accustomed to seeing
high-tech developments created in the military then translated for
civilian use. Makes me smile to think that it is the military that is testing out the deeper integration of licensed acupuncturists for
later export to regular medicine. (Thanks to Stacy Gomes, EdD, vice
president for academic medicine at the Pacific College of Oriental
Medicine for the tip.)

New ethics, standards for naturopathic doctors

Model naturopathic standards of practice and ethics sections expected to be added to Hawai’i law

The state of Hawai’i has passed into law a new section on Standards of Practice, Care & Ethics for naturopathic physicians. The American Association of Naturopathic Physicians honored the state society for its work

in passing the amendments to its practice act, calling it a “model for
all states.”  Some components of the Ethics section include:

• A requirement on “sufficient time” for individualized assessment and treatment (6C)
• Referral (7C)
• Requirement to not only “communicate but to educate” (8A)
  
• Disclosure of any financial benefit from selling natural products (9B)

The Standards of Practice portion includes a
section on the NDs role in health promotion. A focus on health
optimization is declared, as is the NDs responsibility to “encourage a
patient toward independence and self-direction.”

Comment: For individuals not familiar with the primary care naturopathic practice, this document may be a particularly useful read.

Natural Products

McGuffin: Supplement industry calls for FDA to withdraw NDI plan

Industry group calls on FDA to withdraw “hugely flawed” program for new dietary ingredients (NDI)

The American Herbal Products Association has called on the US Food and
Drug Administration to “withdraw” its “hugely flawed” proposal for
regulating new dietary ingredients (NDI) used in herbal and other
dietary supplements. The FDA posted its plan in July of this year. In a December 5, 2011 release, AHPA took the following position:

“Instead
of providing guidance regarding [Dietary Supplement Health and Education Act’s] DSHEA’s NDI notification provision, as
directed by section 113(b) of the Food Safety Modernization Act (FSMA),
the draft guidance seeks to erect extra-legal barriers to market entry,
impose food additive- and pharmaceutical-type evaluative criteria,
require multiple NDI notifications for dietary supplements beyond those
required by law, and transform the legal requirements for marketing of
dietary supplements that contain NDIs from the notification process
described under law to an FDA approval process.”

AHPA executive director Michael McGuffin notes that the organization’s intention is to work with the agency. “One
of the key features of AHPA’s comments is that it includes proposed
solutions that specifically recommend revisions to the draft guidance,”
McGuffin added. “AHPA has provided FDA with a thoughtful, thorough-and
most importantly, lawful-starting point for revised guidance.” The full text of AHPA’s comments are here.

Comment: The American Botanical Council (ABC) took a position

that focused on clarifying “old dietary ingredients. The 501c3
charitable organization urged that an expert advisory panel be created
to develop such a list. The ABC response is here.   Late breaking: AHPA sent a release December 6, 2011 noting that the 5 top trade associations are all calling for the FDA to withdraw the NDI document. 

ACA: Practitioner group weighs in against FDA’s plan

Chiropractic organization suggests regulation of NDIs may require legislation to restrain the FDA; AANP weighs in

In a release entitled “ACA Seeks Preservation of Patient Access to Dietary Supplements”, the American Chiropractic Association notified members that it believes that following a comment period, the FDA plan for new dietary ingredients (NDIs) will be “somewhat improved” over than the original proposal. However:

” … the Association believes it is
unrealistic to expect the FDA to satisfactorily address the full range
of the industry’s concerns, and that the final FDA requirements will
still prove overly burdensome and harmful to the interest of DCs and
their patients. If this proves to be the case, then the ACA and the
supplement industry will have to turn to Congress in order to seek the
enactment of a responsible legislative ‘fix’ to reign in the over-reach
of the FDA with respect to the NDI guidance requirements — and the ACA
fully anticipates supporting and cooperating with the industry in
seeking enactment of the required legislative solution, and engaging the
ACA’s grassroots resources in that battle. The ACA is monitoring the
NDI issue on an on-going basis and will inform its membership if and
when grassroots action is needed.”

A query to the American Association of Naturopathic Physicians (AANP) yielded a response at press-time. Their statement is posted here. The laud aspects of the regulation then note that access to 25% of products on the market may be impacted. Bottom line: “We believe it is in the consumers’ best interest to minimizing the use if overly burdensome regulations that do not impact the issues central to ensuring quality and patient safety.”

Publications

Micozzi’s new book guides consumers to appropriate CAM therapies

Marc Micozzi, PhD, MD co-authors Your Emotional Type with Michael Jawwer

“Your
Emotional Type
may be the Rosetta Stone we’ve been waiting for – a code for matching a
particular therapy to a particular patient. Micozzi and Jawer have
found gold.” So writes author Larry Dossey, MD in his liner note for this book co-authored by long-time integrative medicine leader Marc Micozzi, PhD, MD. Micozzi, the former director of integrative medicine at Jefferson University School of Medicine, was editor of the first textbook on complementary and integrative medicine. The new book appears to be hitting the public as an interesting hybrid: a science-based book, back-end loaded with references, that is also self-help and filled with useful resources. The authors, according to one reviewer, “look at the ways in which alternative healing modalities
work in relation to not only particular illnesses, but also the personalities
of people seeking treatment.”

People

Roger Rogers: Integrative oncology pioneer

In Memoriam: Canadian integrative oncology leader Roger Hayward Rogers, MD – 1929-2011

Roger Rogers, BA, BSW, MD, OBC died peacefully on November 22, 2011 in Victoria, BC. A note from backers of the Dr. Rogers’ Prize award that was established in his name stated simply: “His contributions to the
field of integrative medicine and his tireless efforts to gain widespread
recognition for – and acceptance of – complementary and alternative cancer
treatments in this country have created a great legacy. His warm spirit will be
greatly missed by his family, friends, and colleagues.” Rogers’ work will most certainly live after him. His integrative cancer model, InspireHealth was embraced last year by the government of British Columbia and effectively became provincial policy through a program to roll the model out to 5 new clinics. The biennial $250,000 Dr. Rogers’ Prize award will continue on, regularly gathering leaders of the North American integrative health community in Rogers’ name, to honor leaders among them. Rogers obituary is available here.

The forced exit
of Don Berwick, MD as administrator of the Center for Medicare and
Medicaid Services was a double whammy for the emerging field of
integrative medicine.

Berwick is a knowledgeable advocate

of the core principles of integrative health care. Few policy leaders
are on record as such outspoken supporters. Yet the more profound loss
for integrative medicine is Berwick’s promotion of what he called the “majestic thing” known as Obamacare.

Donald Berwick, MD

Berwick’a alignment with integrative principles became apparent in a
presentation at the National Academy of Sciences in late February 2009.
In a keynote at the Institute of Medicine Summit on Integrative Medicine and the Health of the Public, Berwick ticked off his “Basic Principles for Integrative Medicine.”

• 
  Place the patient at the center.
• Individualize care.
• Welcome family and loved ones.
• Maximize healing influences within care.
• Maximize healing influences outside of care.
• Rely on sophisticated, disciplined evidence.
• Use all relevant capacities – waste nothing.
• Connect helping influences with each other.

Nothing in Berwick’s prescription will jar the multidisciplinary
multitude of integrative health advocates. Patient-centered? Much to the
dismay of the dominant school of medicine, patients arguably created
the complementary and alternative medicine movement. Berwick’s list is
enshrined in the definition of integrative medicine endorsed by the 51 medical schools in the Consortium of Academic Health Centers for Integrative Medicine.

Yet the deeper impact for integrative medicine’s health-creating
orientation is Berwick’s promotion of payment and delivery methods that
mimic incentives in government-directed systems. The very structures
that provoke the ire of Republicans who gave Berwick his pink slip
support integrative medicine.

A growing cadre of integrative medicine professionals recognizes the
acronym jungle of the emerging ACOs (Accountable Care Organizations) and
PCMHs (Patient Centered Medical Homes) as a fertile host for
mushrooming use of integrative care.

Ira Zunin, MD, MPH, MBA is the founder of the 40 practitioner Manakai O Malama PCMH-integrative hybrid in Honolulu. Zunin explains in an interview
that linking electronic medical records with local hospitals
immediately facilitated referrals for his acupuncturists, massage
therapists and naturopathic doctors.

Zunin says the more significant friend to integrative medicine in the
PCMH is the break from fee-for-service. He explains: “You have
unassigned dollars that aren’t directly connected to a provider or a
procedure or a code. Payment plays into the hand of integrative
practice. You can use the dollars from an integrative perspective.”

Zunin adds: “The PCMH model is supposed to help the whole person, in
his or her community. We [in integrative medicine] have always been
looking at everything with a bigger tool set, with a focus on health.
We’re oriented to this model. We’re oriented to teams.”

Tom Trompeter, CEO of Healthpoint,

agrees with Zunin. For 15 years, his growing network of 10
federally-qualified health centers in the Seattle-area has had
naturopathic doctors, acupuncturists, massage therapists practicing
alongside their medical doctors, nurses, nutritionists and clinical
psychologists. In a recent interview, Trompeter told me in an interview
how the PCMH is a “break from the paradigm of a physician owning a
patient.” He says this opens the door to team care and “the team
approach opens the door for diversity” of providers and services. “To
use a well-worn term,” Trompeter adds, “our approach is holistic.”

When I spoke recently with David Moen, MD, the executive medical director with Minnesota’s Fairview Health Services,
he echoed Trompeter: “Many of today’s costs are associated with a lack
of a holistic, integrated approach.” The new outcomes focus of ACOs is
ready made for integrative medicine: “The movement is toward more
holistic measurements of health and well-being.” Moen spoke readily of
the “good evidence that some integrative therapies help a patient’s
ability to cope.” He adds: “Integrative medicine supports
self-efficacy.”

These new structures won’t disappear with Berwick’s exit. In fact,
Moen and others believe that the shift toward ACOs and PCMHs will
continue regardless of any negative judgment by the courts on the
Obama-Pelosi reform.

Moving huge agendas, whether to advance integrative health philosophy
and practice or to restructure the incentives in the system, is not
movement of furniture. Manifesting the principles Berwick outlines for
integrative medicine require culture change. Anyone engaged in such
sometimes Sisyphian work knows that advocacy from the top is not merely
critically important. It is necessary. This is as true for leaders of
new ACOs and PCMHs as it is for integrative medicine’s line-workers.

With Berwick running CMS, the person in the bully-pulpit of the nation’s
most powerful payment system was integrative medicine’s
brother-in-the-trenches. Berwick has a chest full of medals for valor in
campaigns to transform our reactive, wasteful system to one organized
around keeping people healthy.

Berwick will be missed in ways most of us have not yet begun to imagine.

I received a recent query from long-time integrative health leader Roger Jahnke, OMD. Ten years ago he and I had been part of a Task Force from the 2000 Integrative Medicine Industry Leadership Summit that developed something that became known as the Design Principles for Healthcare Renewal. Wrote Jahnke: “I remain inspired by the ‘principles.'” He asked when I thought they might be “resurrected.” 

The Design Principles were well-received by the White House Commission

Jahnke’s note roughly coincided with the November 10, 2011 Integrative Medicine in Action event
sponsored by the Bravewell Collaborative of philanthropists in integrative medicine. There, the comments of Ken
Paulus, the CEO for Allina Hospitals & Systems, reminded me of one of my favorite phrases, in Principle #9: “The renewed healthcare system is a
partnership between an expanded commitment to the public health and a
thriving industry of health creation.”

Paulus’ view that economic incentives are emerging to support integrative health strategies gave me optimism that a “thriving industry of health creation” might yet find room to grow, amidst the perverse incentives of the fee-for-service system. Perhaps it is time for another look at these “Design Principles of Health Care for Accelerating Personal and Health System Renewal.” The 10 principles and their preamble are printed below in their 2011 form.

Background: The suggestion to set up a task force on principles at the 2000 Integrative Medicine Industry Leadership Summit was made by Gary Sandman, presently the president of Signature Supplements. Work began in a January 2001 daylong session in the Rayburn House Office Building of the US Congress. Clement Bezold, PhD, chair of the Institute for Alternative Futures, moderated the discussion. Other participants, besides Jahnke, Sandman and me, were:

• Len Wisneski, MD, now chair of the Integrated Heathcare Policy Consortium
• Pamela Snider, ND, executive editor and founder of the Foundations of Naturopathic Medicine Project
• Writer and integrative health consultant Alan Dumoff, MSW, JD
• Terry Schmidt, PhD currently a faculty member at UC Irvine
• Jery Whitworth, RN, CCP, then a partner with Mehmet Oz, MD in the integrative services department at Columbia Presbyterian Hospital; and 
• Beth Clay, then House Government Reform Committee staff member and now a DC lobbyist.

Ten months later, on October 5, 2001, Wisneski submitted these principles to the White House Commission on Complementary and Alternative Medicine Policy where they were well-received as an important contribution to bringing coherence to the 3-ring circus of all things “CAM.” Subsequent to a review at Integrative Medicine Industry Leadership Summit 2001, Dumoff took the lead on a revised version that was subsequently published in a Liebert publication.

The Design Principles of Health Care

for Accelerating Personal and Health System Renewal

 
Task Force from the Integrative Medicine Industry Leadership Summit 2000
Spring 2001

Preamble

Core principles drive the way healthcare operates and is
experienced. Times of change and disturbance call us to examine, clarify
and commit to renew our individual and community practices. The
following set of principles emphasizes the integrative nature of optimal
healthcare. Such care seeks to create health by engaging new and old
approaches to health for the individual, system, community and
environment. Integrative care is grounded in relationships, seeks
sustainability, is energized by the unknown and crafted through
continuous exploration of strategies for uniting the best of the world’s
evolving practices, outcomes and traditions.



These principles, based on the missions
and visions of diverse stakeholders, are an initial expression of an
effort to create a unifying view of a renewed system for healthcare
delivery and payment. These principles are meant not as ideals, but as
working tools of design, application, evaluation and alignment.

The design principles for accelerating health and well-being in individuals, and in the health system, are:

1. Honor wholeness and interconnectedness in all actions.

Body, mind, spirit, community, and environment are an integral whole
that cannot be separated into isolated parts. All are involved in
healing. Healthcare interventions, regardless of their focus, affect the
whole.


2. Enhance the capacity for self-repair and healing.

The innate capacity for healing and the individual’s personal
empowerment in supporting these natural processes are fundamental
considerations in all healthcare decisions.

3. Prioritize care in accordance with a hierarchy of treatment.

Care, and the leveraging of resources to affect care, are prioritized
along diagnostic and therapeutic hierarchies which begin with education
and empowerment in healthy choices, then move to the least invasive
approaches and escalate, as necessary, to approaches linked to increased
likelihood of adverse effects or higher costs. The starting point for
intervention is established through clarifying, with the individual
receiving care, the risks associated with foregoing, and with
undertaking, more invasive approaches. Chronology and cause are
fundamental aspects of this healing order.


4. Improve care through continuously expanding the evidence base.

Healthcare is a combined art and science in which personal practices
and clinical choices and services are continuously evaluated and
improved, by practitioners, users and organizations, based on diverse
evidence. Included are the desires, perceptions and outcomes experienced
by the individuals at the center of care, the clinical experience and
understandings of all members of a provider team, and particularly,
systematically gathered evidence of experience and outcomes. More
stringent evidentiary standards are associated with higher risk or more
costly interventions.


5. Embrace the fullness of diverse health care systems.

Conventional, traditional, indigenous, complementary and alternative
models of care, and their bodies of knowledge, have contributions to
make to the healthcare which is culturally most appropriate and
effective for individuals and communities. Best practices are discovered
through exploring diverse structures for integration, including
parallel, collaborative and assimilative models.

6. Partner with patients, their families and other practitioners.

Caregivers profoundly enhance healing and strengthen shared
accountability through supporting the informed decision-making of the
individuals/families/loved ones they serve, and through inclusive,
respectful partnerships with other practitioners with whom they
collaborate in care provision.

7. Use illness and symptoms as opportunities for learning and growth.

Illness represents an opportunity in which healing and balance are
always possible even when curing is not. Symptoms are guides to health.

8. Explore integration in one’s own care.

Practitioners, administrators and individuals are most effective in
understanding and delivering integrative healthcare, and in embracing
these design principles, when they follow these principles in their own
care choices.


9. Align resource investment with these healthcare principles.

The renewal of our healthcare payment and delivery systems is fostered
by aligning resource investment, in the personal, public, philanthropic
and private sectors, with these principles. Humble willingness to work
to resolve the tensions between one’s personal and professional
interests, and those shared interests expressed in these principles, is
required of all participants. The renewed healthcare system is a
partnership between an expanded commitment to the public health and a
thriving industry of health creation.

10. Respect the time required for personal and health system change.

Interventions may be swift, but healing, habit change, and transformation take time and ongoing commitment.

Comment: Much richness in these 10. The sections I view as most potent, yet under-expressed in the evolution of integrative medicine since, are the concepts of the “hierarchy of treatment” (#4), the respect for the “fullness of diverse health care systems” (#5) and then, the principle that stimulated this re-publication, the need to stimulate a “thriving industry of health creation” (#9). Thanks to Jahnke for his prompting. Is there yet more value in “resurrecting” these further? 

Other articles in this series:

Rick Kirschner, ND: Author/speaker

Amidst the debate in these pages over the decision of the University of Arizona Center for Integrative Medicine to promote development of a recognized MD specialty board in integrative medicine, I had unrelated reasons to connect with my friend and colleague of over 2 decades, Rick Kirschner, ND.

Kirschner is a best-selling author and speaker to such groups as Toyota, the US Army and the Young President’s Organization. He has made a living over the past 25 years through teaching communication and relationship strategies. In the mid-1980s, he co-authored a set of best-selling audio tapes, How to Deal with Difficult People, which offered lessons on communication in challenging situations. This was followed in the early 1990s by the international best-selling book, Dealing with People You Can’t Stand: How to Bring Out the Best in People at Their Worst. Then came 7 more books, including his recent work on influences, “Insider’s Guide to the Art of Persuasion.” Some focused on people in workplaces, others in their families, and one with one’s self. Kirschner’s most recent is How to Click with People: The Secret to Better Relationships in Business and Life.

I shared with Kirschner my dismay that the antagonism between the integrative practice disciplines can still hit such a furious pitch as was the evident in the responses to the news. Kirschner shared that he had recently learned of the resolution from the American Academy of Family Physicians against full scope naturopathic practice such as is practiced in Kirschner’s homestate of Oregon where he maintains a license.

I invited Kirschner, a non-practicing 1982 graduate of the then National College of Naturopathic Medicine to consider contributing his perspective. Learning to click seemed a good message for discomforted disciplines. Here is Kirschner’s column.

“Recently, I learned that some
frustrated colleagues were talking about pursuing a public campaign to
challenge the claim to authority of conventional medical doctors regarding
ownership of the title of ‘doctor.’ 

Kirschner’s business logo

“Their frustration is
understandable.  Anyone who pays any attention to what is loosely
categorized as ‘alternative medicine’ knows that there are legitimate grievances
for practitioners of natural therapies.  I, too, would like to see things
change, and I’m all in favor of developing strategy to bring about that change.
 

“But what is the best strategy?  Maybe it’s one that is done in the open,
that invites other potential stakeholders to choose sides, but I don’t think
so.  The concern I have regarding this idea of a public campaign at this
moment is that a direct and open challenge is probably the least effective
response possible.  Because it’s bound to be expensive, and it’s bound to
require bodies and minds willing to participate, and I just don’t think there’s
enough of either to get it done this way.  So what possibility remains if
we rule that out? 

		“When somebody doesn’t make the choice to talk to somebody who is opposing them, I’m guessing it’s a lack of confidence …”

“More likely, strategies for further integrating healthcare and relieving
harassment of natural medicine practitioners will, for the foreseeable future,
be done behind closed doors and behind the scene, leveraging political networks
and social capital for positive change.  And there’s only one strategy that
I’m certain about, and it’s the personal one. 

“Whenever I hear that some natural medicine doctor is being sniped at by
conventional docs to whom they’ve sent a referral, are being denied access to
conventional med services on behalf of their patients, or are being
brought up on charges by the conventional medical establishment due to a weak
legal arrangement and overreach by practitioners, it occurs to me that the most
obvious next step for the person seeking change is to reach out to the people
engaged in the bad behavior, and find out what exactly is going on with
them. 

 

“The fact is, people do what they do
for a reason. Sometimes, lots of reasons.  People have their
reasons, and if someone is doing things that interfere with you, a prudent
choice is to attempt to find out what their reasons are.  That requires
connecting, relating, and communicating purposefully and successfully with
someone who, at the face of it, is hostile to you.  That hostility means
they are protecting something they value, something they deem important. 

And the deeper you go, the more meaningful it becomes, and the less effort is
required for change.

“If really changing the health care paradigm has even the remotest chance of success, doctors must leave their silos, and start clicking with people, start building positive relationships.”

“When somebody doesn’t make the
choice to talk to somebody who is opposing them in this way, I’m guessing it’s
a lack of confidence that is holding them back, along with a sense of
isolation.   Otherwise, I think they would first reach out to the person
calling them out, instead of hiring it out to attorneys. 

“Reaching out is the human thing to
do when you’re building bridges and knocking down walls. It is through our
connections that we create healthy communities and alliances, by facing,
surfacing and addressing problems when they arise.  And as things change,
problems do arise. Whenever there’s an interpersonal or interprofessional
problem, finding out what the problem is has to be the top priority. 

“If someone feels under siege, and
they’re not thinking of finding out what’s going on from the people besieging
them, it likely means that they are uncomfortable with making contact and
asking questions.  Perhaps they don’t think they can stand up for what
they’re doing in a personal challenge, or perhaps they fear they’re going to be
lacking in some sort of comparison. I get it, that makes perfect sense.  I
know that if I don’t think I can hold my own on a subject, talking to someone
about it in a respectful and authoritative way just isn’t going to
happen.  Most people are that way. 

“But avoidance is not an effective
response when dealing with a challenge, not if progress and positive change are
the desired result.  In other words, getting together with antagonists and
talking about the antagonism and what’s driving it has to happen.  I think
that at least you have to try.  It demonstrates self respect.  It
demonstrates integrity.  It very likely may create some trust, and a
little trust is a great beginning.  

Click: Kirschner’s most recent book

“If really changing the health care
paradigm in this country has even the remotest chance of success, then I’m
convinced that doctors must leave their silos, and start clicking with people,
start building positive relationships.  Objections are not a bad thing.
 Challenge is not a bad thing. Avoidance ought to be avoided, if at all
possible.   Objections provide a profound opportunity to learn something
about the deep structure of people who seem like your opponents.  Think
about this.  If one of our elders was under attack, there’s no doubt in my
mind that they would pick up the phone and confront it by asking,  ‘What’s
going on?’ 

“If someone is standing in your way,
don’t walk away, walk towards.  Embrace the opportunity of it.  And
get clicking. Because time is passing, and the need for a
paradigm shift has never been greater.  It is unlikely to happen because
of a mass movement.  It is far more likely to happen in relationship,
changing minds one at a time, until we reach a threshold of mutual
understanding and respect.  It will happen through our relationships with
other health care providers.  It will happen from the commitments we make.
 It will happen one click at a time. And that time is now. 

“I’m
reminded of the words of wisdom found for so many years on the Dr. Bronner’s
soap label:  ‘If not you, who?  If not now, when?'”

Comment: Kirschner’s human and humane message can seem terribly naive amidst the vicious guild behavior in medicine. I think there is a place here to apply the therapeutic order, to use a concept expounded by Kirschner’s discipline. By this I do not mean: Step 1: feel victimized. Step 2: sue the MFs.

Step one in these guild issues is optimally self-care in the form of meditation and reflection. The next move is meeting with the other. I agree with Kirschner that a lack of confidence is often in the way of communication. On all sides. Did the AAFP meet with the NDs before they passed a resolution against them? No one wants to expose their weaknesses or those of their own discipline. Each has them. Antagonistic parties have a great ability to spit out the history of the other’s shadow. As Kirschner says: “It demonstrates self respect.  It
demonstrates integrity.  It very likely may create some trust, and a
little trust is a great beginning.”

I believe in steps of trust, even itsy-bitsy ones, and in the planting of seeds even when the ground seems barren. Deserts sometimes bloom.

Later steps in the therapeutic order of political relationships represent the -ectomies of medicine. If the other does not respond reasonably and one is still threatened with senseless harm, more severe courses are asked. The courts are appropriate sometimes. Consider the opening to human discourse and integration forced by the very expensive Wilk vs. the AMA that put a muzzle on the AMA’s efforts to kill chiropractic. Similarly, kudos to a group of family doctors that presently suing the federal government to break the stranglehold the AMA’s specialists have on a health-focused reimbursement policy.

Here is my sense of the application of Kirschner’s recommendation to the move by the Arizona Center. I have sought to model this in my management of the dialogue. Engage the issues. Put yourself in the other’s shoes. For licensed chiropractors and naturopathic doctors who seem the most upset: Urge that the vision of these new MD-BCIM specialists include demonstrating expertise in how to work with integrative practitioners whose education in integrative approaches is deeper and more thorough than is likely to be required of the MD-BCIM. Urge them to tilt the meaning of MD-BCIM away from know-it-all-do-it-all to a models steeped in interprofessional education and respect. Urge them to put this in training and the examination that leads to board certification. 

      
Start with the attempt to clarify and to click. Hope that Kirschner’s wished for transformation of medicine, promised by the integrative MD community, manifests there.