Your Comments: Bradly Jacobs, MD, MPH & Christy Lee Engel, ND, LAc on Rakel's Integrative Medicine
Written by John Weeks
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.
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My review of Integrative Medicine, the influential textbook by David Rakel, MD and 100 other authors, mostly of them MDs, led to some clarifying exchange between the two of us at the article's bottom (Regarding Drop Value, Antecedents and Whether It's All About MDs: David Rakel's Integrative Medicine, July 7, 2008). My focus was on how "integrative medicine" appears, in Rakel's volume, to be by, about and for medical doctors. Our discussion quickly stimulated two excellent responses from long-time participant leaders in the field, one of them the author of a massive, co-authored volume for the American College of Physicians (ACP). Their insights expand the discourse.
Bradly Jacobs, MD, MPH
1. Bradly Jacobs, MD, MPH: "You have to meet people where they are ..."
"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)!"
Comments: I am struck with the depth of experience which emanates from these two practiced experts, the shared commitment to quality patient care, and the relative inanity of quibbling, as it may seem, over language. Then I find myself caught between, on the one hand, Jacobs' closing wish, that "if we don't agree, we walk on the same paths to a common destination..." On the other hand, Lee-Engel references the potential that success in transformation of "[MD] practice into a health creation model" may lead to questions about the need for distinctive naturopathic medical education - that is, entrance to her own field, re-birthed in the US in the late-1970s. So we see Jacobs' two paths, only one disappears, at least under one of Lee-Engel's imagined futures. Did an entire discipline ever declare "mission accomplished" and let go?