Time for a Heretical Model? Ballard, Quinn, Manahan & Simpson on 'Integrative Medicine"
Written by John Weeks
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."
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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
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Bill Manahan, MD
2. Bill Manahan, MD: "I believe it's time to consider the heretical model ..."
Bill Manahan, MD, has frequently offered his fine perspective here. In this instance, Manahan has a number of stakes in the fire: leadership in holistic medicine, an associate role with a leading academic integrative medicine program, chapter author in Rakel's first edition of Integrative Medicine, a collegial relationship with, and respect for, Rakel, and his role,like Quinn, as an Integrator adviser.
"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
"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: "Integrative
medicine: Who writes the peace treaty?"
In 1982, Tom Ballard, ND, was asked by the first graduating class of naturopathic physicians from what is now Bastyr University to be represent them as a speaker at their graduation. Ballard, who also many years in nursing, has most recently spent over a decade providing integrative medicine as a primary care naturopathic physician in the Regence Blue Shield network and for other Washington state carriers.
"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?'"
Comment: Manahan refers to this discussion as an "elephant in the room." I'd say there is a small herd here, easily spooked. One way to keep these large, warm-blooded creatures from destroying the furniture is to talk "transformation" yet urge patience of the non-MD disciplines toward a quiet reform which won't seriously threaten the powers that be. Manahan - and Glidden and Ballard - are being precisely "heretical" in breaking out of that reformist approach. I suspect that for the dominant school of medicine this looks a lot like revolution.
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