New "Effectiveness" Direction for NCCAM: An Interview with Director Josephine Briggs, MD
Written by John Weeks
New "Effectiveness" Direction for NCCAM: An Interview with Director Josephine Briggs, MD
Summary: When Josephine "Josie" Briggs, MD took over as director of the NIH NCCAM in January of this year, she promised to start her tenure "listening" before she would begin to put her stamp on agency. She did, and still is. But she has also found clarity on some new directions. In this interview, Briggs promises an agenda which will focus more on "effectiveness research" and "real world outcomes." A key focal area: pain. Here is the interview with Briggs, engaged for Integrator sponsor IntegrativePractitioner.com. Briggs will be speaking to these issues at a panel I will be moderating at the Februayr 19-21 Integrative Healthcare Symposium in New York City.
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The power of Briggs’ position may be best understood by
reference to an ancient strategy of war. The strategy teaches that those who
control the narrows of a river will control commerce, and the countryside. For
the future of integrative practice, research may be viewed as just such a
narrows. The issue is not just with outcomes, but also the questions asked.
Access, acceptance, integration, reimbursement, integration, the therapeutic order
and much of the ability to transform lives are all downstream from this narrows.
The power of Briggs’ position may be best understood by
reference to an ancient strategy of war. The strategy teaches that those who
control the narrows of a river will control commerce, and the countryside.
For
the future of integrative practice, research may be viewed as just such a
narrows.
Briggs brought a sterling NIH resume to her new position.(1)
She had not, however, much background in complementary, alternative and
integrative medicine prior to taking on her role. She announced immediately
that she planned to spend six months listening and learning. And to all
accounts, she has. She has traveled the country to visit with researchers,
educators and practice leaders from diverse disciplines. To her credit, Briggs also
made time to meet with me in mid-March, despite an Open Letter I wrote at the
moment of her appointment which questioned NCCAM leadership from a scientist
who was not already experienced in the field.
Briggs has begun to clarify her agenda for NCCAM. She
plans some significant, if evolutionary changes. In this late October interview
- a prelude to her Integrative Healthcare Symposium participation – Briggs
offers her perspectives on the new directions NCCAM will take in her tenure.
__________________________
Weeks: Thank you for the time. You announced in your
first appearance with the NCCAM advisory council that you plan to do a lot of
listening in your first six months. I am aware that this has been going on.
Colleagues at Tai Sophia Institute in Maryland and Palmer Center for Chiropractic Research in
Iowa and the massage-focused [Crossroads] clinic in the Beltway and numerous
integrative medicine researchers have shared that you visited or opened your
office to visits and input.
Briggs: I have been struck by the fact that chronic
pain conditions are major problems in health care – chronic back pain, joint
pain, headaches. Honest conventional physicians will acknowledge that they
don’t have all the answers, and many patients seem to benefit from various CAM approaches to managing these problems. We’ll be emphasizing research in these areas.
We anticipate a new program solicitation for non-pharmacologic approaches to chronic
pain management in 2010.
New priorities for NCCAM: effectiveness research
Weeks: What kind
of general approach do you foresee taking?
Briggs: You will see us increasingly invested in real
world, effectiveness-type of research. It’s important not just to look at
research on mechanisms and efficacy trials, which might look at acupuncture
versus sham acupuncture. I think that we need to look at things more broadly.
We need to look at how effective some of these interventions are in creating
better outcomes in settings that are as close as possible to the real world.
There are healthcare implementation questions. You’ll see an increasing focus
on effectiveness research.
Weeks: I would
think that with a healthcare system as haywire as ours that this is an
appropriate direction, in general. Ever since I read a JAMA editorial from some Institute
of Medicine leaders stating
that up to 50% of what we do is waste, and likely harmful, I’ve been
dumbfounded that our research establishment is not redirected toward problem
solving this.
"You will see us increasingly invested in real
world, effectiveness- type of research ... we need to look at things more broadly ... at how effective some of these interventions are in creating
better outcomes in settings that are as close as possible to the real world."
- Josephine Briggs, MD
Briggs: There was a recent NIH Directors meeting
[involving directors of all the Centers and Institutes] where there was
extensive discussion on the role NIH should play in effectiveness research.
It’s fair to say that there is a recognition across the NIH of the importance
of effectiveness research, and that we need to communicate more clearly what we
are doing with the Congress and public. We think our portfolio at NCCAM is
yielding information that is relevant but that we have to be more
proactive.
Weeks: Let’s talk numbers a second. What percentage
of your research dollars do you think should have this more practical flavor?
Briggs: The most important factor in answering that
question will be the outcome of peer review of the proposals we receive, so I
can’t give you a direct answer. I will say that right now greater that 50% of
our research involves human subjects and that percent will continue. Also, we
intend to steer funds more actively in the direction of research on effectiveness
of CAM approaches to chronic pain management with the initiative planned for
2010, and will also place a higher priority on investigator-initiated research
in this area. Clearly the funding for
this will have to come from money that was in other investigator-initiated
areas. Some 10% of our funding is in large herb trials, for instance, and we
are not currently planning to start any new large trials. This might slightly
shift the balance, although we won’t abandon the natural products portfolio.
Review panels, journal reviewers and whole practice models
Weeks: An issue I have learned about from
researchers who are interested in looking at the whole practices of integrative
care is that they believe a significant obstacle to getting whole practice
research funded is reviewer bias. The issue seems to be that
conventionally-trained NIH researchers are accustomed to the relative
simplicity of a single agent drug trial. They give poor scores to trials which
necessarily have more uncertainty involved since they involve multiple modalities.
We joke that many researchers would rather know something that is absolutely meaningless
perfectly well rather than learning something that is potentially very significant but
is surrounded by some uncertainty.
Briggs: Review panels are rightly made nervous by
complex trials in all areas of health research. We need to go into expensive,
large-scale trials with strong evidence of promise and a lot of confidence that
we’ll have a clear outcome at the end. We’d like to understand potential biological
mechanisms in order to design large, complex trials, for instance. Research
design has to be described well enough to be published in a scientific paper.
"I do believe that a more holistic, patient-centered
approach is a major piece of the effectiveness work and will have to shape our
research endeavor."
- Briggs
Weeks: I must add
– not to whine but to point out what may be a structural challenge in bringing
forward whole practice research – is that I have also heard that journal editor
bias is quite like reviewer bias. Neither is comfortable with the real world
uncertainties of multi-modality approaches.
Lessons from cognitive behavioral therapy
Briggs: I do believe that a more holistic, patient-centered
approach is a major piece of the effectiveness work and will have to shape our
research endeavor. But this research is not easy and CAM researchers are going
to have to ask some hard questions. They are going to have to do a lot of
protocolizing of their approaches, which involves some compromises. The field
of cognitive behavioral therapy is a field from which we can learn in this
regard. The field is about 10-15 years old and also employs complex,
individualized approaches. In some cases the therapies are now accepted as the
best. But this only came to be after the researchers got together and came up
with protocols and carefully analyzed the approaches. This would be a direction
for naturopathic research, to describe and define the practice in a way that
can be researched.
Weeks: Another
area of significant interest of which I am aware through work with researcher
colleagues in the Academic Consortium for Complementary and Alternative Health
Care is cost outcomes. Members of the professions out practicing in communities
know that cost data are critical for expanding access. We talked about this
when you and I met in March. Have you plans in this area?
"CAM researchers are going
to have to ask some hard questions. They are going to have to do a lot of
protocolizing of their approaches, which involves some compromises.
- Briggs
Briggs: Cost is certainly one of a number of
important measures of effectiveness. When we met in March you certainly educated
me on the importance of the issue of the costs of poor health and benefits of
wellness over time to an employer. Presenteeism [a productivity measure] is a
substantial cost. This is a valid point. We will see if it’s possible to assess
cost in the effectiveness research that we do. From an NIH perspective
assessing effectiveness must be viewed more broadly than just cost as our
reason for doing research.
Weeks: Well, I’ll
probably keep nagging you that cost be elevated on the NCCAM agenda. At least
at this point, no other agency seems to be asking cost questions related to
integrative practice.
Briggs: Clearly, there is no way that the issue of healthcare
costs is not going to be important for the country.
Weeks: Thanks again
for your time. I look forward to the panel on February 19th at the Integrative
Healthcare Symposium. _______________________
Comment: I recently shared Briggs' plan to support a shift to an effectiveness agenda with a colleague who believes, as I do, that real world research is the best use of resources. The colleague met the news with disbelief. Where is this direction visible on the website? Why wasn't it apparent in the last NCCAM newsletter? Excellent questions. Dr. Briggs clearly knew, since my Open Letter to her last January when she assumed this office, that this was an interviewer who she would please with talk of effectiveness. It will be good to see this direction made visible in other media. Taken seriously, this is a culture shift for NCCAM, not to mention the NIH. To support Briggs move from intent to significant action, my guess is that it wouldn't hurt if she, her staff and her advisory council learned that this is a direction our professional associations, colleges, researchers and educators support. Briggs is accessible. Let her know. Meantime, let's head into Thanksgiving 2008 with some thanks for this new openness at the top of NCCAM.
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Briggs: I am
continuing my outreach activity. Last week, I was at the 
