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Yale Integrative Medicine Gains Acceptance from Medical Leaders, Begins to Flourish PDF Print E-mail
Written by John Weeks   

Yale Integrative Medicine: A Story of Growing Acceptance from Medical Leaders

Summary: Those who have followed the short history of integrative medicine will know that the Yale name has been associated with an integrative clinic for nearly a decade. Yet it was only two months ago that a website at the Yale School of Medicine affirmed that conservative institution's participation in integrative medicine. This article describes the process over the past decade of a public health medical doctor, a Planetree hospital, a medical student and a series of naturopathic physicians quietly "tearing down an Iron Curtain." How? That conservative institution discovered that forms of integrative medicine already existed within its walls. On April 2, 2008, Yale will sponsor an "Inaugural Scientific Symposium" which is expected to significantly advance that academic health center's involvement with the field. More ...
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1.    Introduction: Moving  from "Carve Out" to Integration

In its first phase, the integration of complementary and alternative healthcare with conventional medicine in the United States followed fundamentally non-integrated models. Hospitals developed so-called "integrative clinics" then placed them over there, where they weren't too involved with the hospital's core business. The insurers or managed care firms which "integrated" non-conventional services into benefits plans typically did so through methods called a "carve out." This pricing strategy guaranteed that the money spent would not be mixed with the real money in a core benefit plan.

Yale medical school integrative medicine, naturopathic medicine
Leadership endorsed IM involvement in 2006
So it was at Yale University School of Medicine when a high visibility member of the faculty began to express his personal interest in integrative medicine through professional pursuits a decade ago. A unique clinical model was created in which medical doctors and naturopathic physicians worked side-by-side. The model caught the attention of Oxford Health Plans then a darling of the managed care world. Through James Dillard, MD, DC, CA, then Oxford's integrative healthcare leader, Oxford piloted coverage of these integrated services.

That early integration activity with which the Yale name was associated was all the more interesting for its leadership. The clinic operated as part of one of 28 Prevention Research Centers (PRC) established through a g
rant from the US Center for Disease Control and Prevention (CDC). The PRC provided the base for a CDC grant to explore integrative clinic models in a Tristate (NY, NJ, CT) area. The Yale PRC was also unique nationally in its relationship with a hospital: Griffin Hospital. Griffin happened to be the organizing center of the Planetree model of care, the pioneering hospital organization in promoting patient-centered care. Finally, the Yale physician fronting the Yale-Griffin PRC was, and still is, David Katz, MD, MPHBesides running the PRC, Katz is an associate professor of public health practice and formerly director of medical studies in public health at the Yale University School of Medicine.

All good, and impressive, even. However, for all this confluence of unusual integrative medicine energy, the medical school's portion of the action was fundamentally rootless.
The so-called integrative clinic was off campus, at Griffin, carved out and away, offsite and largely out of mind. Despite the connections, and the CDC grant, there wasn't any pleasing of "Dad." The conservative medical school was having none of this.

The last two years have begun to produce a remarkable new rootedness for integrative medicine at Yale. Two signs are the program's first Yale-based website, and an Inaugural Scientific Symposium
tentatively scheduled for April 2, 2008. To all accounts, this change was fostered largely by the passion and quiet persistence of one medical student, Rachel Friedman.

2.   In which a cardiologist, a medical student and a bookstore employee create a "coat hook" for integrative medicine at Yale

integrative medicine, medical students, Yale medical school, leadership, organizing
Medical student Rachel Friedman - credited with organizing the Yale IM initiative
"It's gaining momentum," reflects Friedman, thinking back on how integrative medicine has begun to be accepted at Yale. She adds: "The real tipping point will be the conference."

That Inaugural Scientific Symposium will showcase what she, two years ago, anticipated she would find when she began quietly organizing. "There were things going on. A lot of mind-body research. A drug researcher looking at the pharmacology of Chinese herbs. There were research and clinical models. My job was to bring people out of the wood work. There needed to be something to latch onto, a coat hook."

The story of how Friedman became that coat hook follows a fascinating sequence. She took off a year between her 3rd and 4th years of medical school to be involved in research. On an NIH fellowship, she was given a cardiologist as mentor. The cardiologist was studying stresses on the heart to examine the effects of "bad impacts." Friedman suggested to the cardiologist that, while they were at it, why not examine what happens with positive impacts. Friedman ended up examining the physiological effects of Reiki on people who had heart attacks.


Yale & Integrative Medicine: Key Dates

Yale-Griffin MD-ND integrative
clinic established, affiliated with the
University of Bridgeport College of
Naturopathic Medicine but with no
formal Yale medical school affiliation
CDC grant to Yale-Griffin center to explore
integrative models in the NY-NJ-CT area

Med student/NIH fellow Rachel Friedman
begins organizing, linking, integrative
medicine at Yale

Yale's medical school leadership
chooses to support Yale membership
in the Consortium of Academic Health
Centers for Integrative Medicine


"Integrative Medicine @ Yale"
website launched


Yale's Inaugural Scientific Symposium on
complementary and alternative medicine




Once she opened the door, Friedman, whose clinical interests focus more on family medicine, started connecting researchers and clinicians. She calls it a "grassroots effort." A key ally has been Don Levy, MA. Levy is the manager of the Yale medical bookstore who is on the board of the Connecticut Holistic Health Association.
Said Friedman: "He sees a lot of people and is very friendly and chatty. Once he knew my interest, he started sending students and other people in the community."

Friedman believes that Yale was slower to get involved with integrative medicine than, say, Harvard, it's not-too-distant neighbor, because "there was a cultural feeling that (integrative medicine) wasn't Yale." But she thinks that this is changing: "If there is more permission to think about integrative medicine, and if there is a community of researchers, more could happen, a lot more. This is Yale."

3.   "A flag planted in virgin territory ... "

"Yale is a bastion of conservative thinking," says David Katz, MD, MPH, who continues to head up the Yale effort. "Yale has a strong commitment to evidence-based medicine. What Rachel (Friedman) has done is identify all the things in the University that are connected (to integrative medicine). She's found activity in medicine, in pharmacology, in nursing. We have ours in public health. She's said, 'look, we have a lot going on.'"

Yale medical school, public heath, integrative medicine, naturopathic medicine, CAHCIM
David Katz, MD, MPH - Yale's IM pioneer
I asked if it hadn't made some difference that the other university with a similar pedigree as Yale has been closely associated in the public mind with exploration of alternative medicine. After the consumer survey by
David Eisenberg, MD and others at Harvard Medical School was published in January 1993, Harvard hosted or co-hosted many of the more visible early conferences in the field.

Katz allowed that, compared to Yale, Boston-based Harvard has always been associated with far more liberal thinking. He added that Harvard's involvement "did make a difference," although it wasn't Harvard per se. Rather, what influenced Yale's dean of medicine was that Katz could point to a group of top-quality academic health centers which had already declared an interest in integrative medicine. These had become members of the now 40-strong Consortium of Academic Health Centers for Integrative Medicine (CAHCIM). Notably, a key membership criterion in CAHCIM is that integrative medicine must have support at the Dean's level or above. Reflects Katz: "I said 'look, here's the cohort we're joining.' There is comfort in looking around at the others and seeing the group and saying, 'this is where I belong.'"

Katz got his Dean's support. In 2006, Yale was accepted for membership in CAHCIM. That membership has, in turn, facilitated Friedman's organizing work. In September, an Integrative Medicine @ Yale website went live. Said Katz: "This is a flag planted in virgin territory."

4.   The Yale-Griffin clinic as "the mouse that roared at Yale"

The dean's blessing was a long time coming. For years, Katz, an internist, appeared to be the only integrative medicine game in town who was connected to Yale.

Fostering an MD-ND co-directed model
The so-called Yale-Griffin integrative medicine center was born
through the initiative of naturopathic physician Christine Girard, ND. Girard, now chief medical officer and vice president for clinical affairs at Southwest College of Naturopathic Medicine, arrived with a $50,000 annual grant to create a naturopathic residency inside the Griffin system. The program was associated with the sole East Coast naturopathic medical program, at the University of Bridgeport. The clinical model evolved as a pilot project based on this initiative.

In the decade since, a
series of ND residents have worked with Katz in a biweekly integrative clinic. Katz and the naturopathic co-director - presently Ather Ali, ND, MPH - do "a pow wow on each patient," in Katz' words. Their roles are clearly demarcated. Katz is responsible "to ensure that all allopathic care is there." The naturopathic physician provides and oversees various natural medicine services. 

Katz uses a medical joke about surgeons and internists to explain his integrative medicine abilities: "Surgeons know nothing and do everything. Internists know everything and do nothing."  He laughs: 'I don't have to know how to insert a pacemaker. I just need to know when to refer to a cardiologist. I am a generalist who needs to know who to refer to and when." Katz adds that he has "evolved" into an integrative medicine practitioner. His integrative clinical strength is in nutrition and nutraceuticals, as well as in knowing when to refer.

Yale medical school, faculty, naturopathic medicine, integrative clinic, researcher, NIH fellow
Ather Ali, ND, MPH - co-chairing the innaugural symposium
Yet while the Yale name is attached, via the Yale School of Public Health and the CDC Prevention Research Center, and while some medical students have observed care at the clinic, Yale medical school still does not have a formal relationship with the Griffin-based integrative clinic.

Still, Katz believes that the existence of the clinic continuously prodded Yale toward more involvement: "In some ways for integrative medicine here, Yale's involvement at Griffin was the mouse that roared."

5.   A sense of the breadth of Yale's integrative medicine activity

Katz anticipates that Yale's conservatism will continue to shape integration activity at the medical school. He notes that of the 3 core areas of medical school activity - education, research and clinical services - at Yale "integration with patient care will be slowest." In fact, even in the more fluid, off campus operation at Griffin, to follow a patient's rare request for inpatient integrative services "practically needed to have an intervention by the government."

Yale's integrative medicine-related education initiatives are described on the education portion of the website. They range from supporting student wellness, to an introduction to a CAM courses, to a senior clinical rotation. This integrative medicine clinical elective includes observations with the Griffin clinic, at a pediatric anesthesiology practice and with "other CAM practices in the area," according to Ali. Of most importance from an organizing perspective are monthly Integrative Medicine @ Yale meetings in which topical presentations are combined with organizational issues.

The website notes three areas where the most research appears to be underway at Yale:
Traditional Chinese Medicine/acupuncture; therapeutic effects of modalities such as meditation, massage, and Reiki; and the physiology and pathophysiology of emotional stress.

Ali also singles out an emerging research program with which Yale is involved: People Reported Outcomes from Complementary, Alternative and Integrative Medicine (PROCAIM). This ambitious, multi-institutional project, organized in part through CAHCIM'S clinical working group, can eventually facilitate efficient gathering of diverse patient outcomes using an array of instruments.

6.   So why is a conservative medical school linked with naturopathic medicine?

I have often felt that the MD-ND model in the Yale-Griffin clinic may have been part of the challenge to greater acceptance at Yale.

Conservative medical doctors are typically more comfortable with unconventional therapies than with
unconventional practitioners from unconventional disciplines. When it comes to such disciplines, acupuncturists and massage therapists are typically more acceptable to the conservative MDs than are  chiropractors and NDs. It did not help that the naturopathic medical program at Bridgeport, while maturing, was hardly the naturopathic profession's version of Yale or Harvard. On top of this, the naturopathic licensing act in Connecticut hadn't been modernized and still read like an old-time drugless healers act.

Integrative Medicine @ Yale, naturopathic medicine, PROCAIM Whatever human and historic elements created that MD-ND linkage with Yale's name attached, Katz has clearly kept pushing the envelope. When Yale joined CAHCIM, Katz appointed Ali, a naturopathic physician, to serve as Yale's representative to CAHCIM's clinical working group. Ali was the first ND to attend CAHCIM's annual working conference. Ali is also high profile with Yale's upcoming Inaugural Scientific Symposium, for which he is serving as co-chair.

"We get some push back," acknowledges Katz, adding: "But there is less-and-less as people meet Ather.  Ather is such a beautiful representative of his profession. He's not starry-eyed." W
hile Ather's ND might not be familiar to Katz' MD colleagues, the rest of his profile is. He earned his MPH from the Yale School of Public Health, in chronic disease epidemiology. In 2004, Ali was awarded an NIH-NCCAM National Research Service Award. Said Katz: "Ather fits right in."

7.   Four months from tipping point, and counting ...

Ali believes that the CAHCIM membership and Friedman's labors created the context for what he believes will be a very successful Symposium. The plan is to feature Yale people, with a few speakers from outside sprinkled in. The planning team recently received the good news that the Symposium had been adopted more deeply into Yale's support structure, giving it more presence. Friedman, who is co-chairing the Symposium with Ali, believes that the meeting will be a transitional moment for all their efforts, as she said, "the tipping point."

Katz evokes another tipping image as he expresses the importance to him of distinctly licensed complementary and alternative healthcare professionals being involved in the Yale exploration: "It's like bringing down the Iron Curtain. We need people on one side pulling and on the other side pushing.
We need to be building cohorts of professionals who are devoted to their art but can speak the language of others."
Added Katz: "Integrative medicine is on the way to taking a respectable place among the disciplines at the Yale School of Medicine."

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