Time for a Heretical Model?  Ballard, Quinn, Manahan & Simpson on "Integrative Medicine" and Inclusion

Summary: The last Integrator issue included views on whether "integrative medicine" is inclusive or denies other disciplines. This set of comments deepens the dialogue. Tom Ballard, ND, part of the naturopathic medical field for 30 years, describes how his excitement about "integration" has panned out as an unhealthy "assimilation." Sheila Quinn, a long-time leader in integrated health care, offers a few perspectives, including that of a patient. Holistic medicine pioneer and contributor to Rakel's Integrative Medicine, Bill Manahan, MD, aligns with a "heretical model" of leveling the playing field. Holistic nurse Sonja Simpson, RN, wonders if any of this will amount to better patient care. Thoughtful submissions on what Manahan rightfully called "an elephant in the room."

Sheila Quinn

1.   Sheila Quinn: the burden of integration should not be solely on the patient

Sheila Quinn's perspective is informed by 35 years of experience in medicine, and by growing up in a family with two medical doctors as parents. A consultant, writer and editor presently, Quinn has been a leader at the Institute for Functional Medicine, a co-founder of Bastyr University and is chair of the board for the Integrated Healthcare Policy Consortium. She is known for speaking eloquently, in all these forums, as a patient of integrated practice. Quinn is an Integrator editorial adviser.

"I had many thoughts (as you obviously did also) on reading Peter Glidden’s outpouring.

"My first thought was, “Well, that’s why an ND has been my primary care physician for more than 30 years!” Would I want a primary care practitioner who was not highly knowledgeable about the full range of non-drug options for most of what goes wrong with most of us for most of our lives? NO.

	Quinn: "The entire burden of integration should not rest on the shoulders of the patient, who must go from office to office, from practitioner to practitioner, and from therapy to therapy to receive the full benefits of integrated care."

"However, for the times when I have had to venture into the conventional medicine arena, would I have wanted to work with MDs who are (a) reasonably aware of the efficacy of natural medicine, (b) moderately competent in some natural therapies, and (most important of all) (c) skilled at interdisciplinary co-management? Well, YES, I would have loved that.

"So, in my opinion, there is an urgent need for integrative medicine, for naturopathic medicine (and acupuncturists, midwives, chiropractors, etc.), AND for integrated health care. That last is my way of saying that the entire burden of integration should not rest on the shoulders of the patient, who must go from office to office, from practitioner to practitioner, and from therapy to therapy to receive the full benefits of integrated care. It should be available in interdisciplinary settings, where the patient can choose the care manager and then that person calls upon all other appropriate disciplines and providers, integrating all the assessment and treatment advice into one chart and one therapeutic program."

Sheila Quinn
3620 Harborcrest Ct NW
Gig Harbor, WA 98332
253-853-4133

Bill Manahan, MD

2.   Bill Manahan, MD: "I believe it's time to consider the heretical model ..."

"Congratulations on another great bunch of articles in the recent Integrator Blog. 

"I especially thought that your review of David Rakel's Integrative Medicine book was your usual fine job of hitting the nail on the head and daring to speak the truth.  I say that as both a great admirer and colleague of David Rakel and as a physician honored to be an author in the first edition of Integrative Medicine.  I will also add that I thought Dr. Rakel's answers were open, honest, generous, and thoughtful - just what I would expect from him.  Let me give an example of that:

"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."

"This is well stated by David, and it speaks to that fine line between stating a truth that resists being discussed (the elephant in the room) and 'creating more conflict' and 'more barriers in doing this work.'

"Regrettably, these reasons that David spoke of so eloquently do not change the fact that, at the present time, the central themes that you state in your article are, unfortunately, truly on target.  Here are a few examples of that:

• "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.
• "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.

	Manahan: "I also suspect that the time has arrived for us to seriously consider having a collaborative model rather then the present hierarchical one.  It is time to consider the heretical possibility that, as Dr. Glidden stated, people should have equal access to all of the healing disciplines."

"Over the past two years, I have read approximately fifty books proposing solutions on how to solve our health care crisis.  There is basically no discussion or consideration in those well-written books about anything other than effective cost controls along with high-quality, coordinated care among medical doctors.  You will not be surprised to know that only one of them (Not What the Doctor Ordered: How to End the Medical Monopoly in Pursuit of Managed Care by Jeffrey Bauer - 1998) even mentions the possibility of having an equal playing field for all types of health care providers.  Peter Glidden, ND, spoke about this fact in this recent issue of the Integrator Blog.  He stated:

"The best any of us can hope for, and certainly the thing that will help the greatest number of people in the shortest amount of time, is not for there to be more clinics where MD’s act as the gatekeepers with the “adjunctive” holistic practitioners employed there scrambling for therapeutic crumbs, but for there to be an EQUAL PLAYING FIELD for all types of licensed medical disciplines."

"Western allopathic medicine does some fantastic things.  We definitely need what MD's and DO's do well.  We are trained to treat disease.  We are not really trained in primary prevention or natural therapies.  It has never made sense to me to expect - or even want - physicians trained in the pharmaceutical and surgical management of serious diseases and problems to be expected to also do a host of other things.  I believe that healthcare would be much improved if a majority of people with health concerns entered the system through a health care provider other than a medical doctor or osteopathic physician.

"I also suspect that the time has arrived for us to seriously consider having a collaborative model rather then the present hierarchical one.  It is time to consider the heretical possibility that, as Dr. Glidden stated, people should have equal access to all of the healing disciplines.  After 40 years of dealing with patients, I believe that people can be given the tools to figure out for themselves what works well in Western medicine and when it would be a good time to see other types of practitioners and healers.  It would truly be the American way to let a person decide for him or herself which type of health care provider to visit.

"I believe that it is time to open the doors wide open and have - as Dr. Glidden says - an equal playing field.  At least it is time to have that discussion.  Thank you, John, for bringing this topic out in the open."

Bill Manahan, MD
Past President, AHMA
Minnesota

Sonja Simpson, RN, MSN, AHN-BC

3.   Sonja Simpson, RN, MSN, AHN-BC: "What a conundrum ... "

"I was intrigued by the piece by Dr. Glidden.  What a conundrum….integrative vs holistic vs. whatever.  There is no mention of relationship based skills which is key to healing….and also sad to say…that the current health insurance systems feeds the total allopathic approach…it will be interesting to see what comes of integrative and holistic and most of all if any of the sorting out will result in improved health care and outcome!"

Sonja Simpson, RN, AHN-BC
Past President, AHNA

Tom Ballard, ND

4.   Tom Ballard, ND:

"I hear the chant 'Integrative medicine' echoing through hospital corridors and convention halls. It conjures up images of inclusion and cooperation.

	Ballard: "Naturopaths began hearing the integration chant a couple of decades ago and it’s become louder. Our hopes were raised that MDs were catching on – realizing there is good medicine outside the pharmaceutical model. Many of us thought we’d be invited into the big wigwam, be welcomed onto the tribal counsel. "I’ve looked in the tent and don’t see integration, but assimilation."

"Naturopaths began hearing the integration chant a couple of decades ago and it’s become louder. Our hopes were raised that MDs were catching on – realizing there is good medicine outside the pharmaceutical model. Many of us thought we’d be invited into the big wigwam, be welcomed onto the tribal counsel.

"I’ve looked in the tent and don’t see integration, but assimilation.

"What happens to any small, relatively weak tribe when it comes into contact with a large and powerful nation? If they’re not slaughtered outright (this was tried by the AMA in the first half of the 20th century), they’re assimilated.

"The word 'holistic' is a good example of how assimilation works. Whole systems science, as practiced by natural medicine practitioners for centuries, is watered down to become a meaningless platitude (and the 'w' dropped, as if it were the study of holes).

"Likewise 'preventive medicine' is assimilated and the meaning morphs from 'avoiding disease by nourishing the host,' to 'early detection' by our new test, read about it in the Wall Street Journal. Prevention was shifted from upstream medicine, where a trickle can be stopped by simple lifestyle changes, to expensive diagnostic testing. This is just one reason for the catastrophic rise in medical costs. Once the trickle turns into a stream, expensive interventions are required.

Ballard: "With MDs slipping under the fence into the pasture I’ve been tending for over 30 years, perhaps I’ll hop  over onto their side. 'Yes,' I’ll say, 'I’ve decided to become an endocrinologist.' "But no, that fence only allows those with certain credentials to pass back and forth at will."

"Sometimes I long for the good old days when NDs were shunned and scorned by the MDs. Now they chat us up and tell us how they’re practicing integrative medicine or functional medicine and their book is about to be published or they’re teaching integrative nutrition to other MDs - and all this with no formal training, often without informal training. With MDs slipping under the fence into the pasture I’ve been tending for over 30 years, perhaps I’ll hop over onto their side. 'Yes,' I’ll say, 'I’ve decided to become an endocrinologist.' I hear the pay's better.

"But no, that fence only allows those with certain credentials to pass back and forth at will. I’m expected to stay on my side and provide 'complementary' support for the medical industrial complex. The peace-pipe is passed among the Fortune 500 and their agents. I’m expected to get high off second-hand smoke.

"I wouldn’t be all puckered up with sour grapes if I’d met any integrative practitioners that really understood what naturopathy was about. Substituting red yeast rice for a statin is not what defines me. What is important is not the treatment; it’s the context of the treatment.

"What I do is ask, and try to answer, 'Why?' Your cholesterol is not high because you’re deficient in red yeast rice or Lipitor. There’s a diet problem or a disruption in metabolic control or both. Let’s find out.

	Ballard: "The question of 'why?' will always lead to a 'natural' answer. Natural is an abused word, another victim of assimilation, but to me a natural remedy simply means something that works with the body’s innate healing systems to restore health."

"The question of 'why?' will always lead to a 'natural' answer. Natural is an abused word, another victim of assimilation, but to me a natural remedy simply means something that works with the body’s innate healing systems to restore health. The organism wants to stay alive, so provide what is native to its needs.

"But such philosophical underpinnings, though supported by wholistic science, are becoming like an ancient chant, lost in the smoke and hand waving that’s filled the tent, given way to the application not of poultice but of product.

"And the young NDs, those that should be warriors for the ancient wisdoms, what happens to them when they enter the integrated tent? There are young NDs who know more about Norvasc than they do the original calcium-channel blocker, magnesium.

"Yes, integrative medicine, I think I know what you look like. I’ve read the history of the American Indian; the long rifle, the small-pox blanket, the confining reservation. What happened to those Native Americans who taught thousands of years of survival skills to the European settlers? If they have any descendants, do they celebrate Thanksgiving? The peace treaty was written in a foreign language and the print was small.

"Integration may sound great in the treaty document, but in practice it murders the old, diseases the young, and corrupts the language. Few will remain to ask 'why?'"