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Regarding Drop-Value, Antecedents and Whether It's All About MDs: David Rakel's Integrative Medicine PDF Print E-mail
Written by John Weeks   

Regarding Drop-Value, Antecedents and Whether It's All About MDs: David Rakel's Integrative Medicine Textbook

Summary: Integrative Medicine, developed and edited by David Rakel, MD, makes quite an impression. The 1238 page volume, with over 100 authors, 97% either MD/DO or medical-school affiliated, marks an arrival and launching pad for that field. The text asserts a body of knowledge and is immediately a political tool for the advance of that field. I was reminded, on reviewing the book's look and feel, of a moment two decades ago when A Textbook of Natural Medicine, was published. That book allowed the re-emerging field of naturopathic medicine to claim it was modeling a new form of science-based, integrated care. What does Rakel's remarkable contribution assert about "integrative medicine" and in particular about the value of other disciplines? Here are my reflections plus Rakel's comments on the book's intent, and some next steps.
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integrative medicine, collaboration, teams
Integrative, with 97% of authors MDs
David Rakel, MD, had a copy of Integrative Medicine (Elsevier) sent to me as background for my Integrator interview with him. This weighty textbook for clinicians and medical students in conventional academic health centers tips the scales at 1238 pages, with chapters from over 100 experts. It makes an undeniable impression. Put differently: the book's drop-value (the power-implied by the look, feel and quick skim of the volume) is of the first order. The volume announces that, despite the fact that the term "integrative medicine" was coined just 14 years ago, the field has great scientific weight. "Integrative medicine" appears to have gone from definition to 60 in record-breaking time.


An antecedent to Rakel's volume

The arrival of the book reminded of a moment two decades ago in an earlier phase of the emergence of the integrative practice movement. In 1985, Joe Pizzorno, ND, kicked off a meeting of the executive team of Bastyr University (then Bastyr College) with a little show-and-tell. Pizzorno unveiled the handsome, impressive product of the first printing of a Textbook of Natural Medicine. Self-published originally by Bastyr in a 3-ring binder, update-able format, and co-edited by Pizzorno's star student, Michael Murray, ND, the Textbook marked a coming of age for naturopathic medicine.


integrative medicine, textbook
David Rakel, MD - a remarkable contribution to his field
Natural healthcare, naturopathic medicine, holistic medicine and the yet-to-be-coined "integrative medicine" had never seen anything like this. Over 56,000 copies of that volume, now at 2300 pages and also published by Elsevier, have since been purchased. The
ND-led project, with a broadly multidisciplinary group of writers (see table), has informed the practices of members of many disciplines. (For reference, the naturopathic profession numbers just 4500 in North America.) A consumer-oriented spin-off, the Encyclopedia of Natural Medicine, has now sold over 1-million copies and has been translated into 6 languages. The Textbook was the prototype of many similarly formatted later works. Examples are those of Melvin Werbach, MD, by the Institute for Functional Medicine, and content produced for numerous medical websites. Rakel's edited text may be viewed as a hybridization of the line of medical publishing which the Pizzorno/Murray Textbook pioneered.



_________________________


  Integration of Scientific Contributors:
Disciplines of Content Writers for Two
Influential Textbooks
on Integrative Practice


Note: These numbers are imprecise. Some contributors
have multiple degrees and are counted more than once.
The table is meant to capture a general picture
rather than
to portray precise numbers.

  


 


 


 Textbook of
Natural Medicine


Integrative
Medicine

Editors

J. Pizzorno, ND
M. Murray, ND


D. Rakel, MD

Total
Contributors

 >90


 >100


MD/DO

 
11


 
100

ND

 50


 1^

PhD*

 12


 2

DC+

 8


 0

LAc+

 11


 0

RD

 1


 2

Midwife+

 2


 0

BA

 0


 2

Pharm

 2


 1

MA

 1


 2

Medical
herbalist

 3


 0

Other

 CCN, JD,

other


 MBA, BDS,

BSN, other

* With no clinical degree.
+ Many were also NDs (and also counted among the 50 NDs)
^ Rakel notes that he approached 6-7; only one chose to write.

_______________________________


Drop value,  bodies of knowledge, and power

But it is an additional value of the Pizzorno/Murray book, beyond its importance as clinical information, which most comes to mind as I reflect on the present and future role of Rakel's Integrative Medicine. Both books have what may be called drop value. Their meaning reaches beyond the sum of the medical references guiding clinicians through specific conditions. Each book asserts a body of knowledge. As such, it is political tool that re-frames perception and dialogue.

   
 
Both books have what may be
called drop value. Their meaning
reaches beyond the sum of the
medical references guiding
clinicians through specific
conditions. Each book asserts
a body of knowledge. As such,
it is political tool that re-frames
perception and dialogue.


In the mid-1980s -, a decade before "integrative medicine" was coined, natural health care of all kinds was disparaged by conventional medicine as unscientific quackery. In this context, the Pizzorno/Murray volume was a door opener for their profession. The weight of the book allowed NDs to argue that the re-birth of the naturopathic profession combined respect for science with naturopathy's known, patient-oriented, time intensive clinical focus. It was an integrative practice model. The naturopathic profession had grounds to claim that they modeled a new form of health care. In addition, the fact that there were MD, DO and PhD authors in the Textbook of Natural Medicine provided some reassurances to those who were a little uncertain, yet, about trusting something written by NDs.

The Textbook has been drafted into repeated use. Leaders at Bastyr and in naturopathic medicine's political causes have gifted the Textbook to scores of key public officials, legislators, members of Congress, insurers, agency heads, journalists and prospective donors. Countless others have been given a chance to glance at the book or leaf through it as part their sizing up of the field.
The Textbook was a best foot forward to skeptical audiences. In short, the volume has had a dual use: education, and political advancement.

So what is the "drop value" of Integrative Medicine?


Rakel's volume, which combines contributions from much of the intelligencia of the emerging field of "integrative medicine," also serves these two purposes. Elsevier would not share total sales, but the book is in its second printing and the publisher called sales "strong." Meantime, the book has no doubt already been used by MD educators to influence decision-makers. Integrative Medicine will continue to announce the weight of the  emerging field to the uninitiated. 

But what are the core messages that Integrative Medicine gives to its audience? What are the dimensions of its quick-skim drop-value? Here are the key messages.


  • "Integrative medicine" is a field defined by and for medical doctors (and osteopaths).
  • "Integrative medicine" is provided and managed by medical doctors.
  • The intellectual content in "integrative medicine" is all developed by medical doctors.
  • MDs from many prestigious medical schools are involved.
  • Thousands of scientific references support integrative interventions.
  • Integrative medicine can be valuable in virtually ever disease.
  • Integrative medicine has a thoughtful approach to the type and strength of evidence. (Rakel and his team designed a useful matrix for weighting evidence, which is used throughout the text.)

In leaving these impressions, there is also much that Integrative Medicine implies by omission.

  • "Integrative medicine" is not about other disciplines, whether acupuncture and Oriental medicine, chiropractors, naturopathic physicians, licensed acupuncturists, massage therapists or even nurses, physical therapists and psychologists.
  • Put differently, these distinct disciplines may exist in Integrative Medicine as therapies that an MD might select, but they don't as distinctly licensed practices reflecting separate, distinct traditions.
  • Members of these disciplines are not intellectual contributors to "integrative medicine."
  • The historical basis of "integrative medicine" was defined and shaped by medical doctors and their allied researchers.

   
 The look and feel of Rakel's book
suggests that
"integrative medicine"
is a
field defined by and for medical
doctors and osteopaths.


 
Much of this impression is seconded by deeper reading. A history of integrative medicine that is part of a chapter on the business of integrative medicine neglects to mention the role of the distinctly licensed complementary healthcare professions in vastly expanding consumer access to non-conventional and frequently mind-body, integrative treatments throughout the 1970s-80s.  Pizzorno's own field of naturopathic medicine does not merit a single reference in the index. (Nor was the Textbook referenced as a platform on which Integrative Medicine was built.) Midwifery is similarly without a mention. Chiropractic, as "techniques," has just 9 references; yet in a chapter on manual therapies, this discipline with 75,000 practitioners merits only a paragraph. Therapies which can be readily grafted on to medical practice, such as acupuncture as needling, supplements, homeopathy, Chinese medicine, herbs and mind-body approaches are well-represented. These therapies can be performed by an "integrative MD" or ordered for provision by an underling, such as a nurse or massage therapist.

Are CAM fields integrative medicine's desaparacidos?

What Rakel undertook, and what he and his co-authors created, is truly a milestone for the movement among medical doctors to advance "integrative medicine" in medical schools and among clinical medical doctors who are the volume's target audiences. Pizzorno, who is editor-in-chief of Integrative Medicine: A Clinician's Journal, volunteered in a quick email in which I asked for sales figures for his books, that he thinks Integrative Medicine is "a very good book."

Yet by virtually excluding all other professions from being visible contributors to Integrative Medicine, the book, intentionally or not, asserts that "integrative medicine" is a field owned by MDs. The table shows how few from outside the MD/DO guild were contributors. Such a contributor list argues that Pizzorno, a naturopathic physician, should not be running a journal with "integrative medicine" in its title.

What explains this? Perhaps these integrative MD are just acting out the historically guild-oriented and exclusionary practices of the American Medical Association. After all, that MDs are medicine's gods has pretty well been droned into them through a decade of awful hours of training. Many outside the MD discipline believe that integrative MDs are blatantly ripping off the other fields. A more friendly view is that this exclusion of other disciplines serves the integrative MDs politically by not shocking their conservative colleagues with a guess who's coming to dinner if "integrative medicine" is invited over.
For whatever reason, the net, harsh effect is that the Integrative Medicine erases from history most of the these other contributory professions to the scientific understanding and the broader public movement on which Rakel's field stands. I know Rakel via the interview and know that this is not his personal practice. Yet in the presentation of this book, these professions become, effectively, the desaparacidos of "integrative medicine."

   
  Desaparacidos

For whatever reason, the net,
harsh effect is that Integrative
Medicine
erases from history
most of the these other
contributory professions to
the scientific understanding
and the broader public movement
on which Rakel's field stands.

 

This is deeply unfortunate, if not utterly unjust. In order to transform medicine and healthcare, an expressed goal of "integrative medicine," integrative MDs must transform relationships between medical doctors and other disciplines, whether these be nurses or massage therapists or naturopathic physicians. Integrative medical doctors must re-frame medicine's prevailing view that medical doctors are owner-managers of both patient relationships and of useful knowledge in the advancement of good health. This will require intentionally including those diverse practitioners who, in the best of therapeutic worlds, will be collaborators in teams of care, often not managed by MDs. This means affirming that sometimes, in fact, MDs will be best used as adjunctive to appropriate, cost-saving, mind-body, integrative practices in which members of other disciplines are in core management roles. Tens of thousands of patients are already empowering broad-scope chiropractors, naturopathic physicians, holistic nurses and other integrative practitioners with these responsibilities.

A place to start in ending the era of segregation in the "integrative medicine" discussion is to see these distinct practitioner types on the contributors' page for what will most certainly be the leading textbook on "integrative medicine" for years to come. To do so will make the top quality work Rakel has already produced into a truly breakthrough volume that exemplifies a new era in health care.

Rakel Responds:  I sent a slightly earlier version of this article to Rakel prior to publication for his comments. He sent back this thoughtful response.
"Thanks, John, for this opportunity to respond.

   
Rakel responds:

"I believe it is important to
understand the intent and
purpose for which this text
was created. Its main goal
was to act as a reference
tool to empower allopathic
clinicians to feel comfortable
recommending non-
pharmaceutical therapies
for common conditions seen
in primary care. It was never
meant to 'define' the field.

"I agree that it would be ideal
to have more non-MD authors."


 
"I believe it is important to understand the intent and purpose for which this text was created. Its main goal from the beginning was to act as a reference tool to empower allopathic clinicians to feel comfortable recommending non-pharmaceutical therapies for common conditions seen in primary care. It was never meant to 'define' the field.

"I agree that it would be ideal to have more non-MD authors. The biggest challenge in finding authors was making sure that the author had a good understanding of pharmaceutical management of disease so they would have insight into how to best integrate this therapeutic modality with the non-pharmaceutical ones. The heart of the book is disease focused and requires an understanding of both pharmaceutical and non-pharmaceutical interventions. I approached 6-7 NDs about writing chapters. All except one declined. Thus in finding authors (not an easy task) I chose those clinicians within my culture that I knew best. I am sure you realize the challenges of getting more than 100 over-worked clinicians to take time out of their lives to write a chapter.

"For these reasons, the bullet points that you list seem a little unfair to me (at least those in the beginning). This was not a conscious intent and I hope that we are able to honor what each profession has to offer while we work towards a common goal. I am concerned though about not recognizing professions who have been doing this work for a long time. It is very important that we give credit to this history and the work that paved the way for a better understanding of how to facilitate health and healing.

"I do feel that we need to be careful in the information that is presented here so we do not cause more tension between professional organizations that could create more barriers in doing this work. After reading this summary, my concern was of creating more conflict compared to acknowledging what we have in common.

"I trust this is not your conscious intent (as it was not mine to over represent authors from one profession) and would love to explore ways to remedy this. One idea would be to have MD/DOs co-author chapters with other professionals such as NDs, Chiropractors, etc. Thanks again for the opportunity to respond."

Dave (Rakel, MD)
My comment back to Rakel:  I wrote back to Rakel with the following:
"I will publicize your note at the end of my piece. It is a good, clear statement of intent. I think that the perception that I captured remains, also. Let me add to this that the same issue exists in the American Board of Integrative and Holistic Medicine training and the make-up of the Planning Committee for the Institute of Medicine's National Summit. (The ONLY non-MD members of the 12 person planning committee are a conventional academic PhD, a consumer and - for all the non-MD fields, a vice president of an acupuncture school who was lobbied on as a representative of the Academic Consortium for Complementary and Alternative Medicine.

"There is a view of disease process which I first encountered in naturopathic and homeopathic thinking that is useful here. Conditions that are suppressed can look like they are worsening when they are surfaced. I intend healing with this, honestly. And I believe we need to look these patterns in the eye."
   
 
Rakel:

"I understand how this is perceived
and realize that how we perceive
the world is what matters most
in developing opinions and bias.

"I look forward to working on
breaking down some of these barriers
so we can create constructive models."


Rakel's last word: When I sent that comment to Rakel, he sent the slightly edited copy to me which I print above, together with a pre-publication article which he wrote entitled "Developing Health-Oriented Teams in Primary Care." The article re-affirms how deeply he is personally committed to collaboration. (It's excellent: I will write it up when it's published!) He also added a comment, a useful story, and a commitment, on which I will take him up:
"I understand how this is perceived and realize that how we perceive the world is what matters most in developing opinions and bias. I look forward to working with you in breaking down some of these barriers so we can create constructive models.

"During my fellowship, one of our lecturers was Rustom Roy PhD (a particle physicist) who you may know. He told a story of trying to get all the basic science divisions (biology, chemistry, physics, etc)  to come together to collaboratively work together. It was an unfortunate failure. Something about human nature gives us comfort when we belong to a clan or group with similar values. Kind of like the collective love of football but the rivalry depicted in Packers and Viking fans! Hopefully the emerging field of 'Integrative Medicine' will allow a new clan to form that brings us together.

"I will look forward to working on this more with you into the future! I enjoy your writing and I appreciate the importance of bringing these important issues to people’s attention."

Dave (Rakel, MD)
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