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Integrative Medicine and Integrated Health Care Round-up: November 3, 2009-December 3, 2009 PDF Print E-mail
Written by John Weeks   

Integrative Medicine and Integrated Health Care Round-up:  November 3, 2009-December 3, 2009

Summary: Examination of Congress' mandate to NCCAM shows gross misalignment ... Synopses of submissions on NCCAM strategic plan from 8 organizations: IHPC, AHMA, AANP, MTF, IAFT, ACCAHC, AANMC and NCH ... New information (and rumors) on inclusion of CAM and integrative practices in US Senate and House versions of health reform legislation ... Nurses urge Harkin against changing NCCAM to "National Center for Integrative Medicine" ... IOM's Summary Report on the February Summit the perfect holiday gift for an integrative practice wonk ... Family Medicine article shows clarity emerging on integrative medicine in residencies ... Joint meeting of two academic consortia celebrated as key moment ... Umbrella specialty Board of Comprehensive Medicine under exploration jointly by AHMA, ACAM, AANP, ICIM, ABIHM, AAEM and IFM ... National acupuncture groups announce 5-year strategic plan ... Holistic medical group AHMA back from the brink ... Rick Rosen, MA, LMT provides excellent overview of the evolving massage "field" ... Nurses add 5-point acupuncture detox to inpatient treatment at Longmont United Hospital ... IAF and Samueli explore whole person "total fitness" for the military ...  Information on the $1-million real world research project with Obama stimulus money going to Marino Center and University of Arizona ... Samueli Institute publishes white paper on cost-savings from a sampling of integrative, wellness and public health interventions ... Kolata's New York Times integrative cancer article draws rejoinder from the Society for Integrative Oncologists' Abrams ... Anti-CAM/IM crusader Novella co-founds new institute dedicated to the same mission ... Gazella expands Community Partners group of the Natural Medicine Journal to 11 professional associations, 8 educational institutions and 3 industry associations ... UCSF-Osher has opening for new fellow ... Info on cost-effective integrative MD practices sought ...    

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Editor's note: Many of us have yearned for decades for more useful evidence of the functional, clinical and cost outcomes from integrative practices. Influencing the strategic planning process at the NIH
National Center for Complementary and Alternative Medicine on the 2011-2015 strategic plan is our best opportunity to create the investment to engage these evaluations. Imagine $60-million plus each year, 50% of NCCAM's budget, devoted to such research. We'd learn a lot, fast. The image has hovered over my work over the past month, and dominates this Round-up.

Research Policy

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Harkin: His mandate pushed NCCAM into the real world of pragmatic research
Examination of Congressional mandate on NCCAM spending suggests original director was wildly out of line in spending priorities

A detailed examination of the 9 key sections in the two-page, 1998 Congressional mandate which established
the NIH National Center for Complementary and Alternative Medicine (NCCAM) concluded that the agency, under founding director Stephen Straus, MD, appears to be wildly out of line with the directions Congress set. The most direct evidence is Subsection (f) in which Congress directly prioritized 6 research activities. Outcomes (#1) and health services (#3) were each above basic research (#4) and randomized controlled trials (#5). The last two, which have eaten up the vast majority of NCCAM investment, were at the bottom of the list, only above "other" (#6). Epidemiological studies is #3. In this first decade, Straus directed only 1% of the NCCAM budget toward pragmatic outcomes. Yet the examination of the mandate, in the Integrator, shows that this real world direction not just in this one section but is structured throughout Congress' language. (See How NCCAM's "Real World" Congressional Mandate is Optimal for NCCAM's 2010-2015 Strategic Plan.)
Comment: The good news about this moment in time for NCCAM is that the current director, Josephine Briggs, MD, is not tainted by Straus driving NCCAM away from Congress' priorities. On this day after President Barack Obama chose on nationla TV to take our nation deeper into his predecessor's quagmire, let's keep Briggs from doing the same. Note, below, that leading integrative practice organizations strongly promote what Congress mandated. The letter from the Integrated Healthcare Policy Consortium says it best. It's time for "tough love."
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Organizations seek to re-direct NCCAM spending in 2011-2015
Stakeholder submissions on NCCAM strategic plan from
AHMA, IHPC, MTF, ACCAHC, AANMC, IAYT, AANP and NCH

The
NIH National Center for Complementary and Alternative Medicine closed the stakeholder comment period for its next strategic plan on November 30, 2009 after extending it an additional 12 days. (At this deadline, some think it still open. Those who want to submit can write directly to the director.) The NCCAM plan will guide some $600-million in NCCAM investments of tax dollars from 2011-2015. These leading organizations, have made their submissions available to the Integrator. Here are brief summaries. The full submissions of each are posted here.

  • Integrated Healthcare Policy Consortium (IHPC) sent an "Alert" to their list stating: now is the time for "tough love" as NCCAM is supposed to support research that facilitates the integration of CAM into mainstream healthcare; seeks more licensed complementary and alternative medicine practitioners on the advisory council; urges funding of pragmatic, outcomes-based research that gathers data on costs and other factors that payers and policymakers use when deciding what to include in their plans. Submitted by Janet Kahn, PhD, executive director.
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IHPC says those who respect the agency need to show a bit of this

  • American Holistic Medical Association (AHMA): need to shift to outcomes-based research from past priorities; suggests title change to "something like" National Center for Integrative Medicine; says "fundamental research on application of integrative holistic practices to produce positive health outcomes" should be NCCAM's focus; notes importance of use of systems methodologies to address systemic problem; plus, calls for "enhanced development of the researcher pipeline and a focus on cost issues with respect to holistic/integrative/CAM coverage." Submitted by AHMA president David Forbes, MD




   
 
The shared themes are a focus on
pragmatic
research, actual practice and
infrastructure investments.


Most commented on the shortcomings
of NCCAM's current basic research
and RCT agenda. All are aligned
with Congress' original intent. 

  • American Association of Naturopathic Physicians (AANP): asks for "development and funding of outcomes-based research initiatives that demonstrate how (primary care organized on naturopathic principles) will enable the transformation of our disease-based system into one that is rooted in sustainable health and wellness;" pushes use of practice-base research networks; wants inclusion of appropriately trained professionals on NCCAM's advisory council and in peer review; and asks for examination of cost issues. Submission shared by Karen Howard, executive director.

  • National Center for Homeopathy (NCH): asks for specific program announcement on basic, preclinical and clinical/outcomes research on homeopathy; urges use of reviewers experienced in homeopathy; seeks scientific information about homeopathy on the NCCAM website; asks for opportunity to submit names for possible appointees to the NCCAM advisory council. Submitted by Nancy Gahles, DC, CCH, RSHom (NA), president.

Comment: First, thanks to NCCAM for extending the deadline and kudos to these organizations for getting their submissions in and sharing them.
Notably, only one of these stakeholders, NCH, promoted basic research, and NCH also requested outcomes research. The shared themes are pragmatic research, costs, and investment in different types of infrastructure. Most commented on the shortcomings of NCCAM's current basic research and randomized controlled trial (RCT) agenda. All are aligned with Congress' original intent.

One significant stakeholder who may or may not have directly weighed in is the influential Bravewell Collaborative of philanthropists in integrative medicine who funded the February 2009 Institute of Medicine Summit. Bravewell calls for changing the reimbursement system, focusing on new primary care approaches for chronic disease and for "a large demonstration project." Examination and development of all these directions would benefit significantly from shifting NCCAM's priorities toward the outcomes and health services "activity areas" for research which Congress mandated.
Again, the full submissions of the 8 organizations are posted here.
Alignment of interest note: I was involved in the creation of the ACCAHC submission and have urged other organizations to respond as stakeholders.

Health Reform


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Action and rumors of action in reform bills
Recent reports of inclusion of CAM and integrative practices in House or Senate reform bills


Caveat emptor: I have not independently verified any of the following reports. My familiarity with the individuals and organizations making them also varies. So this is news and rumors, which I hope will add to your sense that you are actually living in the Beltway where the two
transmorph in every given moment.

  • Direct-entry (homebirth) midwives in the Senate bill   An e-letter from the MAMA Campaign on November 20, 2009 includes this: "In direct response to MAMA advocacy, Senator (Maria) Cantwell (D-WA) has included a provision in the Senate Finance Committee bill that will require Medicaid to reimburse licensed birth attendants (which would include state-licensed Certified Professional Midwives) who provide services in licensed birth centers." MAMA is pushing for broader inclusion. Cantwell's measure is viewed as a start.

  • Health coaching and lifestyle change  The December 2009 issue of Yoga Therapy Today from the International Association of Yoga Therapists includes an interview with integrative medicine leader David Riley, MD in which he is asked about what he likes in the reform bill. He is quoted as responding: "Funding for education in lifestyle changes, healthcare coaching, for example, have been specifically and explicitly mentioned." He notes models from Karen Lawson, MD and from the the Institute for Functional Medicine, adding: "These two programs are included in some of the language of the legislative initiative in healthcare reform before Congress."

  • Naturopathic doctors in Indian Health student loan payback program  The November 2009 e-news from the American Association of Naturopathic Physicians includes a report from Karen Howard, executive director, that "the recently passed House bill includes the entire Indian Health Care Improvement Act (IHCIA) legislation that contains a provision that would make naturopathic graduates eligible to participate in the Indian Health Service Loan Repayment Program." Howard's report also references inclusion in workforce and nondiscimination provisions.

  • Integrative practitioner on CER board A December 1, 2009 release from the American Association for Health Freedom/Natural Health Alliance includes this: "The Senate healthcare bill now requires that the Comparative Effectiveness Research (CER) board to include at least one integrative healthcare practitioner along with healthcare consumers, physicians, private payers, and pharmaceutical and diagnostic manufacturers. It also includes, as appropriate, experts in integrative health and primary prevention strategies on the CER advisory panel. This marks the first inclusion of integrative medicine in any federally designed program." I don't know current leadership of the AAHF/NHA, or anything yet about the merger of the two organizations. The final statement is clearly an overclaim (no program has been passed yet), and the rest of the release, relating to their role in this accomplishment, feels like an overclaim. Nevertheless, the placeholder for an integrative practitioner might be in there.  CAM is clearly on the CER agenda.

  • Two overview stories on integrative practice and CAM in reform legislation  An e-letter to members from the AAHF/NHA includes a review of what they view as other pertinent inclusions. Their list also includes some characteristics of the legislation that are onerous to them. Finally, from another perspective, a release entitled Health Care Reform Bills Legitimize Quackery from the anti-CAM, anti-integrative medicine Institute for Science in Medicine provides its own review. (See story on the Institute, this Round-up.)
  
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Nurses push Harkin to use more inclusive term
Holistic nurses urge Harkin to focus on "integrative health" not "integrative medicine"


The American Holistic Nurses Association (AHNA) has formally requested that US Senator Tom Harkin (D-IA) not move to re-name the NIH National Center for Complementary and Alternative Medicine (NCCAM) the "National Center for Integrative Medicine." Harkin brought up the idea of the name change in public comments surrounding the Institute of Medicine Summit in February of this year. In a letter co-signed by 23 other nursing organizations, the AHNA wrote:
"There are so many in this country who enthusiastically support a vision to put integrative health care at the heart of national health reform.  However, to facilitate this vision; to reinforce a more inclusive, representative, and collaborative partnering of every health and health-related profession and constituency; and to recognize and maximize the valuable contributions of all, we would like to suggest the renaming of the National Center for Complementary and Alterative Medicine to the National Center for Integrative Health and Healthcare. In transforming the health care paradigm, a shift in language can be a critical influence in supporting and adopting  that change. The use of Integrative Health and Healthcare focuses on people’s health and well-being, rather than on a specific profession, and broadens the array of disciplines involved in promoting it."
As of this writing, Harkin had not formally responded to the nurses nor had an Integrator query to Harkin's staff elicited a response.
Comment: The subject is of particular interest at this moment for a few good reasons. The subject of appropriate language to describe this movement weaves throughout the IOM Summary Report on the February Summit. (See related article below in this Round-up.) In addition, the NIH NCCAM's first white paper shaping it's strategic plan speaks at length of the evolving movement for "integrative medicine" without reference to the inclusion issues and the "integrative healthcare" term. (Interestingly, the American Holistic Medical Association recommends NCIM, or something like it, in their submission to NCCAM, noted above.) Finally, this critique of the recent policy book written by Andrew Weil, MD, Why Our Health Matters, suggests the MD-centrism of his use of "integrative medicine" may be getting in the way of the movement for transformation he is seeking to foster. Good for the AHNA to have brought this to Harkin. Thanks to Integrator adviser Carla Mariano, EdD, RN, AHN-BC for bringing this to my attention.
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IOM's report a great integrative sampler
IOM's Summary Report on the February 2009 Summit is the integrative wonk's holiday gift recommendation


Sending someone a download link is a lazy way to fulfill on gift-giving. But here is mine to you. Go to this Institute of Medicine link to download your own copy of the IOM report. Now if you or your colleague or friend is truly an integrative health/medicine wonk, splurge and spend the $52 for hard-copy, also through that link. I did. It's a fascinating read. I found myself reflected on where the movement from "alternative medicine" and "holistic medicine" and "holistic nursing" of the 1980s, and the NIH's early exploration of "unconventional medicine" in the early 1990s, is arriving. I say "is arriving" because this book portrays a field in motion. The top notch IOM staff usefully captures and summarizes perspectives of over 60 professionals in these readable pages. Some of these leaders are deeply im-bedded in one or another part of the root system of integrative health, such as Ornish, Kreitzer, Pelletier, Goldblatt, Guarneri, Sierpina and others. Other are movers and shakers in conventional medicine who are looking in on this emerging field, such as Berwick, Halvorson, Harkin, Cooper, Briggs, Tunis and the IOM's president Harvey Fineberg, MD. The actual momentum of the movement is such that the field appears to have changed during the 3 days of the summit itself. Language palpably shifts in the report from "integrative medicine" to "integrative health."

My review of the IOM book shares that their document is not without its controversies. (See IOM's Inviting Report on the Summit on Integrative Medicine, uh, "Integrative Health Care".)
Repeated suggestions by speakers that distinctly licensed CAM providers such as naturopathic physicians and chiropractors and AOM professionals might help meet the nation's primary care needs appear to have been systematically suppressed, and referenced only as "other providers." Part of the pleasure in reading is getting agitated, finding your own identity by reflecting on what is presented. You'll learn from this, I would venture to guarantee, and you will think differently about what we are involved in accomplishing, on reading in these three score of 1-3 page short sections. Heck, maybe it's a good gift to yourself. Happy holidays!


Academic Medicine

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Lead author Rita Benn, PhD
Family Medicine article explores strategies for weaving integrative medicine into family practice residencies


A challenge for integrative medicine educators in conventional medical schools is how to shoe-horn new content into already over-stuffed schedules. A recent publication
in the November-December 2009 issue of Family Medicine shows how this knot is beginning to be untangled. Integrative Medicine in Residency: Assessing Curricular Needs in Eight Programs reports results of a needs assessment survey used to guide development of a 200 hour program that is meant, in the words of co-author Victoria Maizes, MD, MPH, to be "fully scalable, flexible, and portable." Maizes directs the Arizona Center for Integrative Medicine (ACIM) which is producing the online residency content. Patricia Lebensohn, MD directs the program. (An article about Lebensohn and the program is here.).

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Victoria Maizes, MD, MPH - shaping the integrative program in family practice residency program
The study, led by Rita Benn, PhD, found that program areas of greatest interest to the 222 medical resident respondents were nutrition, supplements and "physician wellness." In addition, "chronic illness, behavioral health, and outpatient medicine were the three top curricular areas seen to need enhancement with IM." Of the respondents, who are from 8 family medicine programs, 67% believed content should be "woven throughout curriculum areas." Respondents who were more familiar with integrative medicine tended to be more likely to support this integration of content. Interestingly, time pressures in current schedules led 52% to urge that total integrative medicine content not be over 100 hours.
Comment: Efforts to shift health professions education, of any kind, can be humbling. Maizes came into a program in Arizonaa decade ago which was then offering a two-year residential fellowship. ACIM, in an earlier incarnation as the Program in Integrative Medicine, responded to real time challenges to physicians of this onsite residency by switching its focus to a demanding but largely online program, which has become a standard for academic leaders in the field. Roughly 600 Fellows in Integrative Medicine have completed the program and are in leadership roles around the United States.

The gold ring for Maizes, Lebensohn and their colleagues, however, is to actually shift family medicine to an integrative model, or rather, to get family medicine to recognize that, optimally practiced, family medicine is integrative medicine. That means getting inside the core curriculum of family medicine programs. 100 hours is probably not enough to be a firm perch for that effort. Here's hoping the 200 hours can actually shift practices. The early focus on physician wellness, rather than merely on additional remedies to add to drugs and supplements, bodes well for the transformational possibilities.

Joint meeting of conventional and CAM consortia (CAHCIM-ACCAHC) celebrated

A recent interview with Wayne Jonas, MD, former director of the NIH Office of Alternative Medicine and CEO of the Samueli Institute, acknowledges a moment of growth in collaboration in the integrative practice arena. Jonas reflected on his observation of a joint meeting of 80 leaders of the Consortium of Academic Health Centers for Integrative Medicine (CAHCIM) and of the Academic Consortium for Complementary and Alternative Health Care (ACCAHC) in May 2009. Jonas stated:
"One of the things that I was very pleased to see in Minnesota at the North American (Research Conference on Complementary and Integrative Medicine) was the pre-meeting that brought together the academic consortium with the consortium of the natural health practitioners. It was gratifying to me to see them dialoging now, explicitly and efficiently. I’ve roamed all those circles for quite a long time and it was wonderful to see them getting together and looking for common goals and possible collaborations.
Jonas adds that his institute "wants to foster that type of dialogue and collaboration and in doing joint research."
Comment: Because I am involved with ACCAHC and was able to attend the meeting, this is particularly nice to see through another's eyes. The meeting is described here through mine. For those interested, ACCAHC's most recent Quarterly Report is available here. The report discusses emerging priority areas for ACCAHC's working groups. 

Professions and Organizations

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Hannaway: ABIHM leader in key role relative to new board idea
Diverse physician groups (MD/DO/ND) explore creation of a board certification in "Comprehensive Medicine"

On October 10, 2009 12 leaders of a half-dozen MD-DO and ND organizations came together to explore what their consultant calls "Setting Criteria for Board Certification." The goal of the group is a single, shared, specialty certification for physician level integrative medicine. The group is reportedly tentatively set on the title of Board of Comprehensive Medicine. One source told the Integrator that the group is planning to apply for formal recognition as a specialty board.

Most of the organizations involved have met over the last couple years under a virtual umbrella called the Integrative Medicine Consortium. Patricipants  in the October meeting included leaders of the American Holistic Medical Association and American Association of Naturopathic Physicians who have been meeting irregularly since 2005. Also participating in this meeting was the certifying body for holistic MDs and DOs, the American Board of Integrative and Holistic Medicine whose president, Patrick Hannaway, MD is the co-chair of the new board committee. A driver of the process has reportedly been Robban Sica, MD, president of the International College of Integrative Medicine, another participating organization. A memo on the meeting made available to the Integrator notes that, of those gathered, "some had already determined that this was an inevitable next step in the progression of their industry, and others came with the intention of simply observing and determining their conclusions later." But according to multiple accounts, concerns voiced at the beginning of the meeting "fell away" as the group saw value in becoming, potentially, a significant specialty board.

The organizations are working with consultant Tony Lynn Chinoy of Harlan-Evans, Inc on their process. The group came out of the October meeting with a series of practical next steps, including: identifying resources of participating organizations; surveying members regarding practice analysis to help set the test; and "determining how to integrate and what pieces are missing." The physician organizations involved in the discussions also include the American Academy of Environmental Medicine, American College for Advancement in Medicine (ACAM) and the Institute for Functional Medicine (IFM).
Comment: Fascinating to see this very practical development. Credit the work of sometime Integrator columnist Bill Benda, MD who began convening integrative primary care level organizations in the spring of 2005. His strategic vision included the idea that maybe some barriers to collaboration would come down if, well, a small set of leaders got out of their, uh, shells. So he convened them at Esalen, where he serves as medical director. For the naturopathic physicians, this level of inclusion must be pleasing. It speaks to the respect they have gained from their holistic and integrative MD colleagues. Notably, the group doesn't appear to include advanced practice holistic nurses. These, via the AHNA, were part of Benda's original configuration. Also not involved are the subset of chiropractic physicians who practice in a broad scope manner. (These were not in Benda's original configuration.) I'll continue reporting this as I learn more. Intriguing development.
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AOM professional group charged with administering 5-year plan
National acupuncture and Oriental Medicine organizations announce strategic plan

Leaders of all the chief national associations representing the acupuncture and Oriental medicine (AOM) field gathered in San Francisco this fall to create a strategic plan to facilitate their profession's more significant involvement in national health reform. A November report from Deborah Lincoln, RN, MSN, RAc, NCCAOM, president of the American Association of Acupuncture and Oriental Medicine (AAAOM) noted that the leaders first created a 5-year vision statement:
Vision: By 2014, acupuncture and Oriental medicine (AOM), an independent, licensed profession, will be fully accessible to the public throughout American health care.”
The strategic plan has four 3-year goals which are meant to help realize the vision:
1) promote research, education, public awareness, and outreach;
2) increase job opportunities for AOM graduates in all health care settings;
3) obtain federal recognition for the profession; and
4) achieve licensure and parity in 50 states and the District of Columbia.
Measurable action items in each of these areas included as wide array of subject matter, including "first-professional doctorate, mutual assistance in publicizing the activities of each organization, inter-organizational cooperation for public relations/marketing, AOM research, AOM graduate success, federal recognition of AOM under Medicare and by the Bureau of Labor Statistics, enactment of new AOM practice acts in states where licensure does not currently exist, and several specific items to promote Asian Bodywork Therapy at the federal and state levels." Lincoln noted that her hopefulness, and that of others, was linked to the "collegiality, passion, and mutual commitment" of the leaders present. The AAAOM is charged with administering the plan's advancement. The leaders will next evaluate their progress in a spring 2010 meeting.

The organizations involved were, beside the AAAOM, the Accreditation Commission for Acupuncture and Oriental Medicine (ACAOM), American Organization for Bodywork Therapies of Asia (AOBTA), Council of Colleges of Acupuncture and Oriental Medicine (CCAOM), Federation of Acupuncture and Oriental Medicine Regulatory Agencies (FAOMRA), National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM), National Federation of Chinese Traditional Chinese Medicine Organizations (NFCTCMO), and Society for Acupuncture Research (SAR)

Comment:  Lincoln noted that the commitment to engage the joint strategic plan came via participation of many of the leaders of these organizations in the February 2009 IOM Summit. AOM has come a long way from its fractious 1990s. To achieve even a fraction of the aspirational goals now guiding them, the organizations will likely need to function in depths of collaboration they've not yet imagined. Running into a few huge bundles of cash wouldn't hurt, either. Congratulations to the field for reaching this milestone and best wishes for greater inter-connectedness.
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Nowack: specialist helps AHMA turnaround
Holistic medical association declares turn-around from brink, shares priorities for coming year


The November 2009 newsletter of the American Holistic Medical Association includes a report from executive director Donna Nowack, CH, CRT, in which she references "AHMA’s successful turnaround over the past two years." She states: "We have successfully restructured, stabilized operations, and set both a strategic vision and path for the future. Our collaborative efforts on a national basis are helping bring together a fragmented industry. [See article this Round-up on the Bpoard of Comprehensive Medicine.] We are even going so far as to suggest the concept of industry consolidation so that all constituents are better served." Nowack then notes priorities: "Our 2010 plans include continued collaboration, development of our local chapter system, stronger connections with medical students and residents, and expanded community outreach."
Comment: The news is interesting, in part because it is immediately followed by an announcement that Nowack plans to leave AHMA. She writes:  "Since my background is as a business crisis manager, and the AHMA is no longer in crisis, it’s also time for us to begin thinking about a transition plan." Here is hoping that the turnabout can survive and thrive with the personnel transition. From my observation point, Nowack has been key to AHMA's survival and new life. Perhaps the future on AHMA is in this phrase in her report: "industry consolidation." We shall see.
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Rosen: a series of key roles in the maturation of his professon
Maturation of the massage "field"/massage "profession" explored


In his recent article The Structure of a Profession: Where Does Massage Therapy Stand Today, author and educator Rick Rosen MA, LMBT, provides a useful analysis of a "massage field" as he notes, which is not the "massage profession." In fact, it is a trade, though many of massage's adherents would like to raise its status. Rosen ticks through massage therapy's structure regarding each of the core elements of a mature profession. I include some of my own comments with his: accreditation agency (multiple routes, only one single purpose, with only 40% of schools with any accreditation and just 6-8% via the single purpose massage agency); professional association (2, one for-profit, the other not-for-profit); council of schools (fledgling, which Rosen runs); certification board (presently challenged and apparently changing its mission); research arm (steady, if under funded). Those interested in more clarity on the field's evolution can access Rosen's 2008 white paper: On Becoming a Profession: The Challenges and Choices that will Determine Our Future. Rosen co-owns and runs Body Therapy Institute in North Carolina, one of the 100+ schools, among some 1500 nationally, accredited by the single purpose accrediting agency, Commission on Massage Therapy Accreditation (COMTA).
Comment: Rosen provides a significant service with both articles. His greater service presently, however, is his work to get the Alliance for Massage Therapy Education, an independent council of schools, up and running. I wish him the best with that.

Integrative Practice

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Longmont Hospital: Nurses to bring 5-point acupuncture into psych unit
Nurses add NADA 5-point needling to inpatient care in Colorado hospital


Nurses in a psychiatric hospital are pioneering inpatient use a 5-point acupuncture protocol according to an article in the November 2009 issue of Guidepoints, the newsletter of the National Acupuncture Detoxification Association (NADA). The use began under an interpretation of a Colorado nursing practice act which allows nurses to do what medical doctors prescribe, as long as they are appropriately trained. The breakthrough was engineered by Jane Crawford, LAc, a staff acupuncturist at Longmont United Hospital, an early leader in integrated hospital care. The inpatient needling program will use two NADA-trained psychiatric nurses. Longmont's Health Center of Integrated Therapies already provides "thousands" of acupuncture treatments in the outpatient envirionment. The 7-bed psychiatric inpatient unit is now the site of 17-30 acupuncture detox treatments a month. Crawford credited the work of Libby Stuyt at Colorado State Psychiatric Institute for "impressing the value of acu detox on the Longmont staff." 

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IAF's Bezold: links with Jonas for exploration of total fitness in the military
Institute for Alternative Futures and Samueli Institute explore "total fitness" for the military


What does "total fitness" mean in the 21st Century? The question has become "a top priority for the military in addressing the health, healing, and resilience of our nation’s warriors," according to the December 2009 newsletter of the Institute for Alternative Futures (IAF). So IAF, led by Integrator adviser Clement Bezold, PhD, joined with the Samueli Institute, led by Wayne Jonas, MD, to convene a group of military and academic leaders December 6-9, 2009 to explore the subject. The workshop is also being sponsored by the Uniformed Services University’s Consortium for Health and Military Performance (CHAMP) and will take place at the Uniformed Services University of the Health Sciences (USUHS) in Bethesda, Maryland.

According to IAF, the workshop will "explore the interconnections between physiological, psychological, behavioral, medical, nutritional, spiritual, and social health in order to provide military leaders with tools and metrics to evaluate programs developed to improve the Total Fitness of military personnel." Academic experts will work with commanders from throughout the military to provide a definition of total fitness that is useful to those serving in the field, according to IAF.  The workshop will provide the basis for guidance to be issued by ADM Michael Mullen, USN, and Chairman of Joint Chiefs of Staff. Papers from the conference will appear in the journal Military Medicine.
Comment: Understanding "total fitness" is a good question for all of us, just as understanding "health" is. The military, like Hollywood and pro-athletes, cares more about performance outcomes than it does about mechanism and is thus quite practical in how it frames its exploration. Too bad 10 years of NCCAM research has cast very little light on these questions. Hopefully the next 10 years will be different. 
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Marino Center: 54,000 visits a year to be basis for analysis under Obama stimulus grant
Marino Center and Arizona Center for Integrative Medicine to examine real world encounters with $1-million of NCCAM stimulus funds


The Marino Center and the University of Arizona Center for Integrative Medicine (ACIM) will, over two years, examine the immense amount of clinical data created daily at the Marino Center to generate knowledge on the comparative effectiveness of integrative treatment. An October release from Marino notes that they will be "looking at real-world clinical encounters as a new way of conducting and thinking about research." The top-flight team includes cost-smart researchers Mikel Aickin, PhD and Integrator adviser Kenneth R. Pelletier, PhD, MD (hc) plus whole systems researcher Cheryl K. Ritenbaugh, PhD, call with ACIM, and a group from Marino including CEO Robert deNoble and researcher Anne McCaffrey, MD. The team is expected to mine electronic medical record (EMR) data on Marino's wealth of experience in two clinics. Together these counted 54,000 visits in 2008, with conventional primary care representing 50% and nine specialty service units ranging from acupuncture to women’s health.

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Lead investigator Mickel Aikin, PhD
The project will look at back pain, fibromyalgia, irritable bowel syndrome, and peri-menopause. 
A synopsis of the plan states: "The focus of this proposal is to create a model project to establish the protocols, based on previously developed methods, by which clinical research from existing data (perhaps modestly supplemented with new data acquisition) can be envisioned, designed, carried out, and analyzed. The long-term goal of the project is to scale this model up to multiple clinics, cumulating an ever larger and more research-useful database for a broad variety of both disease states and therapeutic approaches, which provides patient-centered evidence-based recommendations that apply to the populations of patients who actually present themselves for medical care." The Marino Center, a not-for-profit organization affiliated with Mt. Auburn and Newton-Wellesley Hospitals, offers patients comprehensive, integrated care.
Comment: This award gives us a taste of what we would see if more NCCAM dollars focused on real world outcomes. Notably, the Marino release included defensive language and also an assertion, on the methods to be used: "The research mode represents a departure from traditional medical research, which relies on randomized controlled trials (RCTs) with specific focus. While RCTs remain the gold standard for testing narrowly-focused questions, it has become increasingly clear that not all important questions about the delivery of health care can be answered by RCTs." I look forward to the day when efficacy researchers feel defensive and say:
"The use of the RCT is a departure from typical research by looking at an imaginary world in which individuals are impacted by single events and are then offered single agents rather than examining the effectiveness of multiple therapies and treatments which are typical in effective healthcare for conditions which usually have multiple causes ..."

Economics

Image
Document shows areas for cost-savings
Samueli Institute publishes white paper on 13 cost-reducing integrative health and wellness initiatives


Better Health, Lower Cost: Strategies for Bending the Cost Curve is the name of a recent publication from the Samueli Institute's Wellness Initiative for the Nation. The 17-page document offers "examples of wellness, integrative health care and public health promotion practices that could transform the nation’s health and reduce costs." The set of 13 initiatives fall into 2 categories and are each presented, in a graphics-rich layout, on a single page.

 Approaches with broad
health and cost impact
    
Approaches with specific
health and cost impact

     
 Integrative Health Care    Military Resilience
 Lifestyle Prevention    Train the Brain
 Lifestyle Treatment    Acupuncture
 Clinical Prevention    Touch
 Community Approaches    Be Still
 Worksite Programs    Lighten up
     Omega-3s

The Samueli paper aggregates studies from an array of fields, inserting integrative health care/integrative medicine in between Safeway's corporate wellness initiative, Ornish style intensive lifestyle interventions and community health promotion initiatives.
Comment: This document, meant to support the WIN initiative, is the rare case statement of the economic value from integrative interventions. Of most interest, strategically, is how the "CAM" approaches (touch, acupuncture, herbs, mind-body) are woven into a public health, employer and lifestyle coalition of like interests.  

Media

Image
Kolata: research doesn't support natural health claims on cancer
Kolata/New York Times article blasts natural health for cancer, ISIO responds


The chart on the full-page spread of the November 13, 2009 New York Times lists 7 things under the title "What Has Not Been Shown to Work" against cancer. Noted are beta carotene, exercise, fiber, fruits and vegtables, losing weight, low-fat diet and selenium and vitamin E." The article, poorly titled Medicines to Deter Some Cancers are Not Taken, was written by Gina Kolata as part of acknowledging the 40th year of the war on cancer. Kolata includes quotes from investigators of these approaches who hold onto their beliefs that there is value in the approach, yet they have problems with methods available to them. The observational studies, one notes, are simply not being conducted to "reveal more reliable information." Donald Abrams, MD, the incoming president for the Society for Integrative Oncology, which met in New York at the time of the article, responded:

Image
Abrams: friendly, sharp response from integrative oncology leader
"I am here in NYC becoming President of the Society for Integrative Oncology. I had just enough time to scan your front page article before heading to the NY Academy of Medicine for the meeting. And I was at the American Institute for Cancer Research Nutrition and Cancer meeting in DC last week. Not surprisingly I was disappointed with your article, especially as we try to move to a system of health care delivery that might promote health and well-being as opposed to disease management. Your observations that the only things that work to reduce cancer risk are pharmaceutical prescription drugs and that lifestyle modification is futile is a real blow to the attempt to have the American public become more responsible for their health. Studies of diet, and exercise as well, are much more difficult and problematic to conduct than a randomized, placebo-controlled intervention involving a swallowed pill! Nonetheless, (why) only highlight the negative when just last week the Journal of Clinical Oncology ran an article on how lifestyle (nutrition and physical activity) decrease the risk of second breast cancers. Meyerhardt from the Dana Farber has been very prolific writing articles which clearly demonstrate the detriment of the 'Western' diet and the benefits of physical activity - especially in colon cancer!


"Even though I disagree with your thrust, hopefully your article will stimulate the same sort of questioning that you aroused in me so that there may be a net benefit. To lull your readership into believing that what they eat or how much they move won't affect their cancer risk reduction is unfortunate! Especially at this critical juncture in our health care reform attempt.


"We have disagreed in the past as well. I was just struck by the timing of your article which I will critique during my acceptance speech this afternoon!


"Good to communicate again anyway!"


Donald I. Abrams, MD
Chief, Hematology-Oncology
San Francisco General Hospital
Integrative Oncology
Abrams' comments were sent to SIO members as part of a Thanksgiving greeting on November 25, 2009.
CommentIn truth, the headline of the chart is a mis-statement. In at least three areas (exercise, fruits and vegetables, losing weight) the small print in Kolata's article shows evidence as conflicting rather than "shown not to work." It was astonishing to see the headline writer, if not Kolata herself, overstating the case against using healthy lifestyle and natural health to combat disease. What motivates that behavior?

Image
Novella: turns anti-CAM avocation into institute
Anti-CAM bloggers create new organization to advance bi-polarization in medicine


Steven Novella, MD, a founder of an anti-CAM blog has announced that he and a group of his anti-CAM colleagues have formed an organization to further their ends, the Institute for Science in Medicine. They describe themselves as a watchdog group of medical professionals who "believe the best science available should be used to determine health policy and establish a standard of care that protects and promotes the public health." In addition, the Institute will "oppose legislation that seeks to erode the science-based standard of care and expose the public to potentially fraudulent, worthless, or harmful medical practices or products." Novella notes that of particular interest are bills supporting naturopathic licensing, health freedom and "stealth promotion of dubious treatments in the proposed health reform bills in the US House and Senate." The latter was the subject of their first press release.  
Comment:  Novella and crew are devoted not to science but to polarizing the conventional medicine-integrative practice dialogue by treating the former as though it is always science-based and the latter as though it always isn't. They are an unpleasant lot whose means of advancing the dialogue includes calling for the de-funding of NCCAM. The rule to follow in this kind of politics is to pay attention to what they are up to, but pay as little as possible. Then wash your hands afterward.
Image
Gazella: what will she do with the Natural Medicine Journal platform?
Open access Natural Medicine Journal expands its community partners base


The open access Natural Medicine Journal announced on November 5, 2009 an expansion of its group of Community Partners  to now include 11 professional associations, 8 educational institutions and 3 industry associations. The groups each agree send the electronic monthly to their lists. The professional groups range widely, with membership from diverse practitioners: MDs, DOs, AOM, advanced practice nurses, chiropractors, naturopathic physicians, homeopaths and integrative oncologists. The November 2009 issue features an interview with Wayne Jonas, MD (which is cited above) and the December issue an oncology roundtable featuring Donald Abrams, MD
Comment: This journal, the brainchild of longtime natural health publisher Karolyn Gazella, is effectively aggregating many of the leading organizations in the field. The only similar grouping is that of the participating organizations of the North American Research Conference on Complementary and Integrative Medicine. It remains to be seen how much Gazella and her editorial team will allow the publication to be used as a base for policy-related discussions and campaigns.

Miscellaneous

Corrections, plus UCSF-Osher research position, request for info on cost savings from integrative MD practices, SIO turnout

Corrections:
In the Integrator article on International CAM, South African actuary Heather McLeod was misrepresented as Heather McCloud. In addition, the acronym FCER (the now defunct Foundation for Chiropractic Education and Research) was inadvertently used in place of F4CP, the Foundation for Chiropractic Progress. Thanks to Chuck Simpson, DC for pointing that out.

Postdoctoral research fellowship opportunity: The UCSF Osher Center for Integrative Medicine is recruiting for its post-doctoral Training program, a 3-yr. program in clinical research in CAM and integrative medicine, with access to training in related basic science methods, and the opportunity for fellows to conduct their own research. Detailed information at:  http://www.osher.ucsf.edu/research/TRIM.html

Information sought: Chris Skisak, PhD, president of Corporate Health Management Solutions is seeking information on "a seminal paper or two that discuss improved health outcomes and even perhaps financial outcomes resulting from physicians providing a combination of allopathic practices and integrative practices when compared to allopathic medicine alone?" The information is for Houston’s Wellness Conference, January 14-16, 2010.

Miscellaneous The Society for Integrative Oncology (SIO) drew 300 participants from 19 countries on 6 continents, according to new SIO president Donald Abrams, MD ...

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