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Readers Say Research "Whole Practices" - NCCAM Needs Focused Program PDF Print E-mail
Written by John Weeks   

Readers Say Research "Whole Practices" - NCCAM Needs Focused Program

By a resounding margin, the subset of readers who chose to participate in the recent Integrator poll favor directing research funding toward projects which focus on evaluating "whole practices." In the poll, readers were asked whether these were favored over "reductive single agent trials."
_____________________________

Funding of CAM-IM research should prioritize
"whole practices" over reductive single agent trials

Response
 
Strongly agree
 35
67.3% 

Agree somewhat

8

15.4%

Disagree somewhat

4

7.7%

Neither agree nor disagree

3

5.8%

Strongly disagree

2

3.8%

Poll ran from July 7, 2006 - through August 17. 2006. Roughly 2% of
the Integrator site's
unique visitors in that time participated.
_____________________________

Comments:  The focus of research funding is one of the more profoundly political processes in integrative care. In classic, strategic, war terms, research is one of the narrows in integration's river. Control the narrows and you control the commerce that flows up and down the river. From the narrows, you see what's coming and you can exact a tithe in both directions.


In classic war terms,
research is one of
the narrows in the
river of integration.

Control the narrows
and you control the
commerce that flows
up and down the river.

Control the narrows,
and you decide
whether single agents
advance, or
whole practices.


Investing in reductive, single agent, randomized controlled trials (RCTs) guarantees that the commerce in CAM focuses on what we have historically called CAM-grafting. Thumbs up on glucosamine for arthritis or needles for a pain condition and these can be readily grafted on to conventional practices.

Threatening, or Empowering, from a Guild's-Eye View


Now imagine that reports begin to emerge that the "whole practices" of
acupuncture and Oriental medicine (AOM), of naturopathic medicine, of holistic nursing, of some standardized integrative MD approach, are effective, and (heaven forbid!) cost effective, relative to conventional treatment. Commerce in the integration discussion would shift from modalities (single botanical agents, acupuncture needles, etc.) to disciplines and whole practices.

Such projects would give us a chance to see whether new paradigms of practice may be more effective than the dominant reductive, time-constrained, suppressive, pharmaceutical models. I don't know about you, but these questions - assertions, actually - are what got me interested in this whole dialogue 23 years ago. My interest in bettering the health care someone pays to use or deliver has deepened my personal bias toward answering whole practice questions that have fiscal notes attached.

Image (My bias was obvious in the framing of the poll question.
What would we have found if the statement had read: "Funding of CAM research should focus on single agent trials instead of loosy-goosy 'whole practices' research ...")

Of course, such a whole practices focus can quickly get very personal and threatening, or, alternatively, empowering, from a guilds-eye view. If I am a political operative for the dominant school of medicine, or for the pharmaceutical industry, I am not sure that I would much care to see projects funded which so challenge the status quo which I control. I'd probably come down pretty hard against tests which might dislodge me. (And if this seems paranoid or conspiratorial, take a look at the Integrator article(s) on the dismantling of the Agency for Health Care Policy and Research.)

Then again, if I were a paid operative for a profession which posits an alternative paradigm of care, I would probably come out pretty strongly for research that looks at what it is my members do, and the cost outcomes of the way they practice. (Not surprisingly, the naturopathic medical profession is calling for exactly this. See references, below.)

Insidious Biases Against Examining Whole Practices

I have no evidence that there is any such pressure influencing NIH decision processes. I have gathered, however, from whole-practice advocating colleagues that such overt, heavy handedness is not necessary. The reason is that reviewer bias leads to scores on grant submissions which make it almost impossible to compete with research projects which present reviewers with the big, shiny red apple of a single agent RCT.


Given the bias
against these models,
researchers interested 
in whole practices
don't submit for
projects which are
their passion.

The cycle of ignorance
repeats itself.


In talking with a half-dozen researchers interested in whole practice research, I have gathered that proposals are scored competitively, with whole practice models competing  against more accepted models. The bias against the complexity of whole practices research extends not just to NIH reviewers, but also to peer-reviewers for publications. The outcomes may be viewed as "less-publishable." Given the bias against these models, researchers interested in whole practices don't submit for projects which are their passion. They submit instead for what will feed them. A body of knowledge and research practice does not, therefore, grow. And the cycle of ignorance repeats itself.

The most telling story was from a respected researcher on acupuncture who was repeatedly steered away from an acupuncture-plus-Chinese herbs intervention. Finally, the research submitted only for Chinese herbs.

In what century will we finally look at the whole practice of the whole-person approaches which include counseling, herbs, supplements, foods, stress management, exercise, self-care and etc. 
Members of our numerous integrative and natural health disciplines are routinely providing this kind of care, this very minute, to tens of thousands of people.

Shouldn't research reflect what people are doing? Shouldn't research funding focus on understanding applications which might have the most significant benefit as we seek to better health care?


Image
Carlo Calabrese, ND, MPH - Whole practice research advocate
Calabrese: NIH NCCAM Should Sponsor a Focused Whole Practices Program

One researcher with whom I spoke, Carlo Calabrese, ND, MPH, suggested a practical starting place for getting us out of this destructive cycle. Calabrese, is presently a member of the NIH National Center for Complementary and Alternative Medicine national advisory council. He suggests that NCCAM develop an initiative which only targets proposals for whole practices projects. He recommends perhaps an R-21 mechanism, which has a $400,000 limit in three years: "It's a way to get started."

Why the focused project? "Reviewers are unaccustomed to the methodological differences that whole practice trials call for." Calabrese doesn't believe we need to empanel new sets of whole practices saavy reviewers. Rather: "If it's whole practices vs whole practices, reviewers can then just address the whole practices methodology they think is best."


We will advance
a body
of new paradigm
research methodology
which is necessary
if we are ever to gain
the value of new paradigm,
whole person
healthcare practice

for our nation's failing
medical system.


Conventionally-minded reviewers, who have neither experienced whole person care nor engaged whole practice research - who are not acculturated to enjoy the tastes of garlic, red pepper and onions in combination - will then simply have to hold their noses and eat. Who knows, like children sheltered from culturally-diverse culinary pleasures, they may end up with some acquired tastes!

This direction for NCCAM seems a no-brainer. In doing so, NCCAM would step another rung in advancing a body of new paradigm research methodology which is necessary if we are ever to gain the value of new paradigm, whole person healthcare practice for our nation's failing medical system. Here's hoping the staff and the rest of the advisory council do what they can to take this idea and make this irso.

References
:

The Naturopathic Medical Research Agenda: The Future and Foundation of Naturopathic Medical Science. Leanna Standish, ND, PhD, LAc (Principal Investigator), Carlo Calabrese, ND, MPH (Co-Principal Investigator), and Pamela Snider, ND (Co-Investigator). Journal of Alternative and Complementary Medicine, Vol 12, Number 3, 2006; 341-345. [Note: The "Agenda" was the outcome of an NCCAM grant to the profession.]

Are Health Services Research Methods a Match for CAM? Patricia M. Herman, ND, MS, Karen Huyvetter, ND, MS-HES, M. Jane Mohler, MPH, PhD. Alternative Therapies in Health and Medicine. 2006; 12(3):78-83.)


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