Bradly Jacobs, MD, MPH & Christy Lee Engel, ND, LAc on the Discussion of Rakel's Integrative Medicine

Summary: My back-and-forth with David Rakel, MD, on the meaning of "integrative medicine" as it is presented in his influential textbook of the same name led to two quick responses from excellent observer/participants in the integrative practice arena. Bradly Jacobs, MD, MPH, directed the integrative clinic affiliated with the UCSF Osher Center before taking his present position with Revolution Health. Christy Lee-Engel, ND, LAc has been a principal or affiliate with the two most significant integrative clinic initiatives in Seattle and has also held leadership positions at Bastyr University. Here are their perceptive enrichments of this discussion.

Bradly Jacobs, MD, MPH

1.    Bradly Jacobs, MD, MPH: "You have to meet people where they are ..."

Bradly Jacobs, MD, MPH is a senior medical director for Revolution Health Networks for which he also writes a blog (Dr. Brad on Conventional and Alternative Medicine). Jacobs, an Integrator adviser, was formerly the clinic director for integrative medicine program developed at University of California at San Francisco school of medicine. Jacobs, as he notes, is co-author of the ACP volume.

"Thanks for sharing with us your thoughtful and honest thoughts about Rakel’s textbook and allowing him to share his responses. 

"David said '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.'

	Jacobs: I would argue that you are more likely to consider something different from what you are accustomed to/trained in if you hear it from ‘one of your own’.

"Given this premise, one must consider how does one best communicate and convince conventionally oriented MDs to consider an integrative approach to patient care?   I would argue that you are more likely to consider something different from what you are accustomed to/trained in if you hear it from ‘one of your own’. 

"Let’s be honest with ourselves -  people are fearful of what they don’t know or understand.  You have to meet them where they are—that means hearing it from someone who shares the same professional training, and speaks the same language etc.  They are far more likely to consider something different from what they know under these circumstances.

"Now you may argue that I am biased and I am motivated to pre-empt a similar commentary from you when my book gets published (“The ACP Evidence Based Guide to Complementary and Alternative Medicine”,  published by the AmericanCollege of Physicians and due on bookshelves in January 2009).  Following your logic when you say, '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', you could argue that I am suggesting that ‘CAM’ is a field that should be owned by MDs—needless to say that I don’t feel this way.  Does it dampen the damage in that I acknowledge the dozen or so CAM practitioners and thought leaders in the preface of the book who provided me with critical commentary on the Appendix that provides a framework of the field and individual CAM professions?  Following your logic, I would argue that it doesn’t.

Jacobs: In both of our cases there are very few CAM providers that have EBM training and are condition-specific specialists.

"In my case, we required authors to be formally trained in evidence-based medicine and apply their knowledge using the GRADE working group approach.  In both of our cases, however, there are very few CAM providers that have EBM training and are condition-specific specialists. 

"I share David’s primary aim which is to reach out to conventionally trained doctors and whisper in their ear in a voice, tone, and language that puts them at ease.  Remember the end game—awaken the heart and mind of MDs to an enlightened path—one that encompasses multiple approaches regardless of origin (i.e. without prejudice) and with the primary focus on one thing— reducing the suffering of their fellow man/woman.

"We may not always agree but as long as we can agree to the following approach- I am OK with that: If we cannot share a similar path, may we walk on paths that take us to the same destination and may we retain the integrity and respect due to ourselves and to each of the healthcare professions that share our common goal (reducing the suffering of their fellow being).

"With continued respect,"

Brad Jacobs, MD, MPH
Washington, D.C.

Christy Lee-Engel, ND, LAc

2.   Christy Lee-Engel, ND, LAc: "A 'New Testament' asserts that it replaces an 'Old Testament' ..."

Christy Lee-Engel, ND, LAc is is a principal with One Sky Wellness, a Seattle-based integrative clinic with 8 core practitioners including integrative MDs. Lee-Engel is also adjunct faculty at Bastyr University where she is presently involved in exploring issues relative to the integration of Bastyr's various disciplines inside the university structure.

"I just took a look at the Integrative Medicine textbook article. I like Rakel's willingness to engage with your comments in a respectful and non-defensive way, and I like his overall perspective in the earlier interview you did with him, very much. Clearly he is health-oriented and cares about practicing good medicine which I define as 'medicine that is good for people'! He reminds me of my friend Dave Kiefer who is also originally from the UW Madison med school, is a family practitioner, & did the 2-yr residential fellowship in Tucson.

"Nonetheless, and even though unintentionally, the fact that the Integrative Medicine textbook stands on the shoulders of, but leaves out mention of, the distinct history and contributions of the natural medicine disciplines does remind me of my rabbi's remark that calling a bible 'The New Testament' inherently asserts that it replaces the 'Old Testament' which is now obsolete (or worse, as you say, desaparacido). Jews usually call them 'the Christian bible' and 'the Jewish bible.'

Lee- Engel: "My original practice partners and I have always thought of 'integrative medicine' as the personal, internal, individual part of our work ...and then we talk about 'collaborative care' rather than integrative medicine."

"These language choices, which I know I for one can get obnoxiously picky about, do influence what we think. My original practice partners and I have always thought of 'integrative medicine' as the personal, internal, individual part of our work. For example, I (am still learning to) integrate naturopathic medical practice and acupuncture and Oriental medicine practice, but what's more important is the whole system, the network, of care we offer, which includes the whole team of our practice partners - and includes as partner the patient who is at the center - and then we talk about 'collaborative care' rather than integrative medicine.

"So, 'integrative medicine' to me has become a term that refers to all the training and information that an individual practitioner swallows and digests - including all those 'cherries' they might have 'picked' off of whole-discipline trees. I have to say, I do that too. A striking example of the course can be generic viagra. I've picked up techniques here and there from craniosacral courses, from drainage seminars and nutritional therapy seminars, from five-element acupuncture which is not my original training, etc, that I've swallowed and incorporated into my eclectic practice...kind of a Borg-ian assimilation ;-)

	Lee- Engel: "'Integrative medicine' to me has become a term that refers to all the training and information that an individual practitioner swallows and digests - including all those 'cherries' they might have 'picked' off of whole-discipline trees. "I have to say, I do that too. I've  picked up techniques here and there ..."

"I guess there is a vague addendum to my comment that is still not completely formed in my mind, which is that I'm still trying to figure out 'what would be best,' how sometimes it seems best that every medical student should learn everything that's really useful from both conventional and natural medicine, plus acupuncture, and Ayurveda, etc, too if it interests them, since if conventional medicine education does really transform into a health-creation model someday (and isn't that the ideal?), would there still be anything distinctive about naturopathic education? And sometimes it seems best that we continue to have distinct branches of medicine, that only rare individuals can really learn it all in depth anyway, and that we just figure out how to work together respectfully and on an equal footing, for the best care...

"And another part of that is, as my 5-Element friend & teacher David Ford says 'we each become our own tradition of medicine' through our individual life experiences and by assimilating all the different insights and techniques we encounter in our studies. In a way, each of us is either an integrative practitioner (changed by life in an ongoing way) or a dogmatic one (unthinkingly loyal to the form we have come from)!"