Yale Integrative Medicine Gains Acceptance from Medical Leaders, Begins to Flourish
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.
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 grant 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 Planetreemodel
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, MPH. Besides 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 Symposiumtentatively 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
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
1998
CDC grant to Yale-Griffin center to explore
integrative models in the NY-NJ-CT area
2000
Med student/NIH fellow Rachel Friedman
begins organizing, linking, integrative
medicine at Yale
2005
Yale's medical school leadership
chooses to support Yale membership
in the Consortium of Academic Health
Centers for Integrative Medicine
2006
"Integrative Medicine @ Yale" website launched
2007
Yale's Inaugural Scientific Symposium on
complementary and alternative medicine
2008
__________________________________
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.'"
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.
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.
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." While 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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