21st Century Medicine: Co-Authors Jones/Hoffmann, plus Jim Whedon, DC and Kara Fitzgerald, ND Respond to the Review of IFM's Exceptional White Paper

Summary: If there is one must-read document on health reform to come out of the broader integrative practice community this year I would repeat, as I said in my earlier review, that it is 21st Century Medicine from the Institute for Functional Medicine. Sit down for an evening and let yourself learn. These additional perspectives, from NIH fellow and Dartmouth health services researcher James Whedon, DC and from Kara Fitzgerald, ND of Metametrix Institute offer useful insights from two disciplines that were not directly treated in the text. Co-authors David Jones, MD and Laurie Hoffmann, MPH share more on functional medicine's relationships with these other disciplines as well as efforts to penetrate medical schools. Larry Dossey, MD, also offers a supportive perspective.   

Institute for Functional Medicine

The Integrator article Health Reform: IFM Declares the Value of Functional Medicine in Exceptional White Paper on 21st Century Medicine, August 8, 2009,

James Whedon, DC

1.  Dartmouth health services researcher James Whedon, DC

Jim Whedon, DC is located at perhaps the most influential health services research shop in the US: Dartmouth University, base of John Wennberg, MD, MPH. The summer 2009 issue of Dartmouth Magazine reports that Whedon, "

"In 21st Century Medicine, Jones et al have articulated a vision of how Integrative Medicine can fit into and contribute to healthcare reform.  They go beyond the hot political issues of cost, access and disparities in utilization to address the real core issues: conventional medicine neglects primary prevention, has failed to stem the ballooning burden of chronic disease and now faces impending crises in primary and geriatric care as a result.  The paper is a timely and important contribution. 

I agree that Functional Medicine looks a whole lot like Naturopathic Medicine in new clothes. But I don't see this as co-opting ­ that is not what the IFM people that I know are about.  To quote the white paper, p 41:

"There is a danger that integrative medicine physicians will extend their practices beyond the scope of their education. Completing a program in integrative medicine does not turn an MD or a DO into a trained chiropractor, acupuncturist, naturopathic physician or other such practitioner. It is important that those who wish to fully practice an alternative discipline seek comprehensive training from accredited institutions, just as those who wish to practice as medical doctors must do."

And these from (IFM's) The Textbook of Functional Medicine, p 28:

• "Functional medicine is discipline neutral. ­ The field is accessible to any health practitioner who has a fairly standard western medical science background. There are significant advantages to this 'neutrality', particularly as the nation's healthcare system becomes more and more open and adaptive to integrative care concepts..."

• "...functional medicine helps create a bridge between conventional and alternative practitioners and approaches..."

• "...This common meeting ground will enhance the delivery of care and contribute to the development of respectful and productive professional relationships among healthcare providers."

"The political reality is that conventional medicine is the 500 lb gorilla in the room, and healthcare reform is going to be framed in medical terms. The IFM white paper provides us with a vision of how that can happen in the way that brings everyone to the table.  I believe and hope that this is indeed the future of medicine."

Jim Whedon, DC
Health Services Research
Dartmouth Institute for Health Policy & Clinical Practice Trauma Program
Dartmouth-Hitchcock Medical Center
Lebanon, NH 03766

Comment: I wasn't actually thinking co-optation, and I thank Whedon for pointing out these sections from the IFM's Textbook. Part of the white paper's value is that it is discipline neutral and therefore an interdisciplinary platform.

David Jones, MD

2.  IFM lead author David Jones, MD on the philosophical underpinnings

IFM president David Jones, MD begins his comments with gratitude for the review and then offers additional insight into his perspective on the treatment of other integrative systems of care.

"I have read your work for many years with great interest.  Your incisive remarks about our document touch me. 

"When the paper was completed to this point (we intend in the next few months to add a final chapter containing two very robust case studies that demonstrate the methodology), I felt that it represented 35 years of clinical practice and 24/7—365 days of wondering about what was right in medicine and what was so seriously wrong about it that it seemed a betrayal of intent. We needed to understand it to help change it, and those musings eventuated in this paper. Having Sheila (Quinn) as main editor and co-writer again (we co-edited the Textbook of Functional Medicine) was god-sent as was the piercing eye of Laurie Hofmann who kept us focused throughout. Again, I greatly appreciate the time and thoughtful thinking that has gone into your review.

If you scratch the surface of most functional medicine oriented practitioners you will find that they have studied and often practiced one or the other of these “whole systems —whole person” methodologies.

"You asked in your editorial about naturopathic medicine, as well of acupuncture and Oriental medicine and broad-scope chiropractic in reference to the different solutions that have been proposed.  My response is that if you scratch the surface of most functional medicine oriented practitioners you will find that they have earlier in their careers studied and often practiced one or the other of these “whole systems—whole person” methodologies.  They were pushed in that direction because of a lack that that they perceived in their conventional training.  What was missing for them in conventional medicine was a coherent foundational philosophy that mapped forward to the clinician’s dilemma of how to solve complex, chronic illnesses. 

These whole-system methods had foundational principles that theorized how the dysfunctions, but fail to deeply embrace the precision of the scientific method nor integrate them into daily practice.

"As you know, conventional medicine’s philosophy is not very comprehensive: 'Come see when you are broken and we will assess the most broken of your organ systems and use pharmaco-surgical measures to treat your broken-ness.'  There is no breadth or depth to this philosophy, no foundational notions of how the system wobbles into brokenness; conventional medicine’s philosophy is sadly barren.  However for these practitioners, the traditional whole system methodologies (as mentioned above) were also unsatisfactory but for the contrary reason.  These whole-system methods had foundational principles that theorized how the system wobbles into dysfunction, but fail to deeply embrace the precision of the scientific method nor integrate them into daily practice.  

"At IFM, we consciously integrated the traditional principles (I once did an exercise with a group of traditional practitioners where we mapped their core principles to the functional medicine principles and except for the principle of vitalism, the mapping was exact) WITH the rich and robust understandings that have been gifted to the healing arts from the biological sciences.  Along with that integration we developed a method for clinical applications of assessment and therapeutics that guide the clinician’s appropriate use of most of the established methodologies both conventional and traditional.

"I hope this helps with some of your questions.  I would welcome further dialogue that emerges from your reading/thinking about a 21st century model for healthcare."

Sincerely,
David Jones, MD, President
Institute for Functional Medicine

"Thank you for the excellent review/summary of IFM's 21st Century Medicine white paper in the Integrator blog.

"Regarding your two questions: I think by year-end we'll have an update that we can really talk about and will then be appropriate to publish regarding functional medicine in medical schools. There are several medical schools and residency programs (in addition to graduate nutrition programs, osteopathic medical programs, and naturopathic programs) that are introducing functional medicine into their curricula. I would not say they are putting the functional medicine "model" into their programs yet; what seems to be consistent across these varied programs is initially an elective course that provides the opportunity for students, faculty, and administrators to evaluate the merits and interest. Thus far, there has been very positive feedback - so much so that the elective courses and seminars are being expanded.

Can't make names of schools public yet

"We're not ready to make public the names of the schools and programs we're working with just yet. We don't want to jeopardize the pilot projects or the faculty who have stuck their necks out to introduce functional medicine to their students and colleagues. Again, we should have an update by year-end.

"In terms of your second question about receptivity and feedback from the white paper, we have just completed the drafting of a comprehensive dissemination plan to include academicians, clinical faculty, clinicians, policymakers and elected officials, health and medical websites and blogs, professional associations, etc. If there is anyone specifically that you'd like us to send the white paper to, please let me know.

"In terms of reviews, we've just begun to solicit them. Joe Pizzorno just completed a review that will be published in an upcoming issue of IM and the foreword by (Victor) Sierpina & (Adam) Perlman certainly serves as a review. In addition, here is a review from Larry Dossey." (See below.)

Laurie Hoffmann, MPH
Executive Director, IFM

Larry Dossey, MD

4.  A Note from Larry Dossey, MD, on 21st Century Medicine

Here is the quote Hoffman shared, from author and editor Larry Dossey, MD:

"I know of no document that so clearly, succinctly, and compellingly charts a path forward into twenty-first century medicine as this.  Dr. David Jones and the IFM staff have their fingers firmly on the pulse of medical science and healing. This document should command the attention not only of physicians and other healthcare professionals, but also of anyone in a leadership position in the evolving landscape of healthcare in America."

Larry Dossey, MD, Executive Editor]
Explore:  The Journal of Science and Healing

Kara Fitzgerald, ND

5.  Kara Fitzgerald, ND: Teaching the IFM "matrix" to ND students

"Nice review of the 21st Century Medicine white paper. The document is a goldmine. An amazing piece of lifework created by the IFM. It's inspiring and will be something I reference and forward to others for years to come, I am sure.

"I thought about naturopathic medicine during my read as well (for obvious reasons). And I was glad that it was mentioned, albeit briefly. We are ideally suited to step in and participate in the solution to the chronic disease crisis, and we are steeped in the concepts taught at IFM. That said, I think NDs could gain much from the structure IFM employs, including the Matrix.

"I presented earlier this year on systems medicine, the IFM Matrix and functional laboratory testing at grand rounds at a number of the US ND medical schools. The students seemed genuinely interested in the IFM structure, as it’s very helpful for capturing and organizing complex data into meaningful and clinically usable ways. I would like to see it taught or more widely available in our schools as well as conventional medical schools. Fortunately, according to 21 Century Medicine, it does look like that’s happening.

Kara Fitzgerald, ND
Her blog is here: Metametrix Institute