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Frustration with Integration: Perspectives of an Academic MD, Winterstein, Sportelli, Anonymous ND PDF Print E-mail
Written by John Weeks   

Prejudice and Integration: Perspectives of an Academic MD, Two Chiropractic Leaders and an Anonymous ND - plus a Therapeutic Scream

Summary: While assembling reader comments, I discovered that 4 spoke to the very significant issues we face with "integration." I group them here. They begin with an anonymous medical academic speaking on the likelihood that Nutritional Medicine textbook author doctor Alan Gaby, MD will receive an academic appointment. Then, the failure of the National Prevention Strategy to include integrative perspectives led university president Jim Winterstein, DC to reflect on the challenges of leadership for those accustomed to "the back of the bus." Finally, NCMIC Group president Lou Sportelli, DC and an naturopathic doctor (who also did not wish to be on the record) each muse on why integrative medicine Fellows from the Arizona Center for Integrative Medicine have trouble starting integrative medical practice. I am reminded of Liza Minelli, in Cabaret, under the train overpass.
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I was surprised on pulling together recent reader comments to discover that 4, each from long-time colleagues with 20-45 years of experience in the field, express with significant emotion the challenging environment in which the effort to appropriately "integrate" continues to operate. Two did not write for attribution. Credit the two chiropractors for being visible.
Though I don't wish to stimulate the spiral of polarization, all of these voices merit airing.

1. Academic MD: On whether academic medicine will give a post to nutritional medicine expert Alan Gaby, MD

In my review of Nutritional Medicine, the voluminous textbook written by expert Alan Gaby, MD, I noted the comment of Jonathan Wright, MD, that Dartmouth or some other medical school should give Gaby a professorship. This sparked the following from an observer of academic medicine and complementary and alternative medicine.
"Well, you are right: he SHOULD get a professorship somewhere but all those positions are reserved for the academic careerists who have been stuck in their ivory towers for their entire careers, climbing up the 'ladder.' Those in CAM who have tenured positions are generally from among these careerists who jumped on the CAM bandwagon when their own careers in some "regular" field of medicine stalled out ...

"Academic careerist transplants from
other disciplines with nil or marginal
CAM credentials
have sopped up whatever
in-house support for CAM 
may exist."

"That is to say, someone toiling up the academic ladder at P. U. figured out they could get up quicker jumping into CAM - which most did not want to touch back when we all got it started. That means, they will make sure that no genuine leaders get 'their' new jobs, let's  say those who wrote the books that everyone now uses conveniently when they create new courses to go with 'their' new positions- without having to do the hard work of actually creating a valid curriculum, or having had to stick their own pencil necks out in the early days when the pioneers made it safe for them to go into the water. This should be very obvious to all by now. The French have a term: 'arrivistes'.

"Although my frank comments are not meant for attribution, I think there should
be a sober article about the state of CAM in 'academia,' the unwillingness of academic medicine to 'marry' CAM experts when they have been [messing with] them for nothing or next to nothing, all these years. Why buy the cow when you get the milk for free? Academic careerist transplants from other disciplines with nil or marginal CAM credentials have sopped up whatever in-house support for CAM may exist."
Comment: I view integrative medicine, generally, as a very positive movement for medicine. And, while there are many leaders and practitioners in that field who are deeply knowing, respectful and inclusive, there remains a boulder of truth in these comments. Some in academic integrative medicine definitely deny the pioneer practitioners and would re-invent an entire field. Some would say they co-opt it. (See the additional comments, on other matters, below.) With clinical outcomes as busted as our nation's, given the sickness in our population, a little radicalism is in order. Bring Gaby and the likes of him who have deep clinical expertise, inside academia's gates. Then let the debate begin.  

Jim Winterstein, DC
2.  Jim Winterstein, DC: A reflection on integration stimulated by non-inclusion of "integrative practitioners"

In Integrator Round-up #40, I noted that the new
National Prevention and Health Promotion Strategy "needs community response to maintain the law's inclusion of integrative care (and) integrative practices." For Jim Winterstein, DC, president of National University of Health Sciences, this non-inclusion of integrative thinking on prevention and health promotion sparked a reflection on the recent history of integration and an early encounter with exclusionary prejudice.
"Ironic, isn't it, John, and yet I think we could have expected this.

"Forty-seven years ago at about this time of year, I was an Army Medic - x-ray technician at that time. The MD radiologist who I worked with, who had always been very friendly to me (he was officer and I was enlisted) was on night duty in the hospital as was I. We were waiting for some radiographs to come through the processor and he said: 'Jim you are getting to be a short-timer. What medical school do you expect to attend?' When I told him that I was thinking about chiropractic college, he went ballistic. This led to a 2 hour argument during which he said many irrational things but one thing stuck in my mind. He said 'I don't care if you brought a million patients through this hospital and cured them all from every disease known to mankind using chiropractic care, I would still call you a quack, because that is what I was taught in medical school and that is the way it is!'

"When CAM practitioners have
been mandated for years
to sit in the back of the bus,
it is not easy to become its driver."

"Now, I do think we have come some distance from those words, but not NEARLY far enough. For decades now, allopathic members have criticized the idea that better food leads to better health; have warned against the dangers of exposing oneself to the sun; have supported the value of white bread and white sugar and have called every form of complementary and alternative medicine quackery and charlatanism - UNTIL now, when it (allopathy) plans to drive the 'prevention and health enhancing' practices - meaning - earlier detection by expensive procedures and tests, expensive 'preventive' drugs like the Statins (which were stolen from a centuries old Pacific Rim food), and oh yes, by probably eating better too.

"Even today, when so many people are interested in better health habits (at least that is what we hear), when it comes right down to being sick MOST people do not turn to a CAM provider, but run (not walk) to the nearest allopath for care saying "My doctor is the best in the Midwest" - did you ever hear of one that is not the best? Allopathic care is a 'social disease' from which people will not easily recover!  When you (CAM practitioners) have been mandated for years to sit in the back of the bus, it is not easy to become its driver."
Comment: Winterstein's final comment is particularly telling, and actionable. Lately, in my work with leaders of the licensed "CAM" fields, I have been something of a broken record on the theme, perhaps out of impatience with myself. The level of complaint about the dominant school of medicine among CAM practitioners has always been intense. But why expect that those schooled in a reductive paradigm would ever understand anything differently. So my refrain: Pull yourself up by your bootstraps into leadership, especially since you are rarely being invited. Or, as my eldest sister said to me years ago when I was covering trade issues in Seattle and had a typical policy journalist's fancy of running for office instead of reporting it: If you want to be a Port Commissioner, start acting like you already are one.

That's not easy for an outsider. Interestingly, Winterstein, in his day job, is creating what I believe is a potentially exceptional base for leadership from the "CAM" disciplines. He is transforming a former stand-alone college of chiropractic into
a university of natural health sciences. National University of Health Sciences presently also houses programs in acupuncture and Oriental medicine, naturopathic medicine and massage therapy. It also has a growing research department. (The other leading examples are Northwestern Health Sciences University, Southern California University of Health Sciences and Bastyr University.) Such multi-purpose institutions potentially the bandwidth and broader mission to embrace the leadership role that conventional academic centers have in policy. 

Lou Sportelli, DC
3.  Lou Sportelli, DC: "Article on challenges of integrative MD Fellows  is truly telling ..."

The publication of the survey by Richard Schneider, MD that revealed the employment challenges facing integrative medical MDs who completed the Fellowship in Integrative Medicine at the University of Arizona stimulated these musings from Lou Sportelli, DC. Sportelli is president of NCMIC Group, the Integrator's founding sponsor. Sportelli began with, "John just some thoughts," then continued:
"Your article by Dr. Schneider is truly telling. Cliches such as 'a rose by any other name is still a rose' could be converted to 'prejudice by any other name is still prejudice.' Whether you call your integrative practice CAM, Complementary, Natural, or Naturopathic, Chiropractic, Integrative Medical or any other name, you still run into the same issue.

"What we want is about changing a paradigm, a medically-controlled mind set. And it's not just a mind-set, it's an economic engine geared to funneling money into the same old model. It's a resistant so-called 'science' based profession which has no desire to: A) change; B) share authority; C) share a piece of their economic pie; D) share cultural authority; E) share dominance.

"Dr. Schneider as a medical physician 
still cannot break the barriers to entry
because he dared to venture into
territory that has been deemed
unscientific ..."

"Dr. Schneider as a medical physician (one of 'them') still cannot break the barriers to entry because he dared to venture into territory that has been deemed 'cultist,' 'unscientific,' 'alternative' or any other pejorative name historically used by the unelected Fourth Branch of Government, the AMA. 

"Dr. Schneider is to be congratulated for being bold and more importantly for recognizing that health care is not 'medical care.' Health care that is meaningful for patients is a system that brings together all of the dimensions, physical-mental-spiritual, into a cogent understanding of how people and their belief systems affect their health.

"The real underlying issues of the failure of the (integrative medicine) concept as Dr. Schneider finds are the lack of reimbursement, lack of allotted time to understand the patient, lack of legal progress catching up with the needs of the doctor, and lack of economic emphasis for funding practices that are outside of the current model. 

"Peer pressure whether from teenagers or medical physicians plays an important role in the acceptance and recognition of integrative practices. It is time for our government, hell-bent on healthcare reform, to begin to TRANSFORM the thinking and make it OK to be integrative, complementary, alternative, traditional or any other name that seems appropriate in order to refocus on the patient that is suffering not because the system is working but rather because the system is not integrated."

Comment: As a person who spends a good deal of time supporting a practice of integration in a world that remains largely inhospitable to the concepts, I often mute my more antagonistic and angry responses to patent insanity. I mean, why are conventional medical leaders who claim to be pursuing 'patient-centered' care not going to school on the kinds of patient outcomes that are secondary to these practices? Such outcomes are likely common denominators across the practices of colleagues of chiropractors Winterstein and Sportelli's as well as those of integrative MD Schneider.

One wishes to will the transformation, and yet the structural resistance to change is huge. Consider Sportelli's reference to "the Fourth Branch of government, the AMA." The phrase sounds inflammatory, hyperbolic. Yet once one takes into account the AMA's ownership of the CPT codes and its powerful RUC committee that shapes Medicare priorities, Sportelli's choice of words is close to pure description.
The poisonous spiral of polarizing continues.

Every now and then, for health, one needs to join Liza Minelli under the train overpass in Cabaret for a little scream therapy.

4. Naturopathic doctor diagnoses the practice troubles of integrative MD Fellows

I received the following from a long-time naturopathic medical doctor who wished it not to be attributed to him. He too responded to the
survey by Richard Schneider, MD in which Schneider found that many of his integrative MD fellows were challenged in making a living as integrative medical doctors.
"Unfortunately this program illustrates the problem of simplifying and gutting non-allopathic approaches to medical care.

"I did an in-service 10 years ago for [a well-known integrative health center]. After a careful analysis of ten cases of typical patients at their facility I was able to tell them why they were losing revenue and why the average patient life at their operation was ~ 2 1/2 visits. The program was being overseen and structured by MDs with insufficient didactic and clinically mentored background in non-allopathic medicine.

"The program was being overseen
and structured by MDs with insufficient
didactic and clinically mentored
background in non-allopathic medicine."
"The Arizona Fellowship has failed to grasp this and I must say that I am not surprised that most of the graduates from the program are failing. Besides that fact that their delivery model allows insufficient time and compensation for the physician bent on earning at the rate that their purely allopathic colleagues garner, they have only marginal classroom exposure to the deeper essence of the craft and virtually no significant clinical exposure.

"My advice to them is to bring their income expectations into line with those of us involved in healthcare and not disease management and get a real exposure to the heart and soul of healing by putting their practices on hold for 24 months and going to the last two years with the 2500 hours of clinical residency at [the naturopathic medical programs at] Bastyr or National.

"Perhaps worse than the health food store owner who diagnoses and treats out of the back of his shop are allopathic physicians who understand so little about what it is that they are purporting to do that they don't even understand where their shortcomings lie. This practice constitutes a real and substantive threat to public safety.

"In point of fact, the influence and impact of diet, nutrition, lifestyle, supplementation, and the gestalt of ND interventions so focally impact drug response, hospital experience, surgical successes, etc. that it may now be unethical for MDs to practice independently from ND oversight. It's only a matter of time before the attorneys extinguish these so-called integrative practices and eventually the programs that spawn them. Maybe even moving us into true national health care where NDs are the PCPs and MDs operate as specialists in suppression and ablation."

Comment: The legal future envisioned by this naturopathic doctor is so unlikely, given the power relationship between medical guilds and actual harm from an integrative MD ractice, that it reads like a wishful scorched earth policy. Still, I too have wondered at the challenges of opening an integrative medical practice if one has not had deep clinical experience or mentoring. Skills in the arts of tailoring and personalizing integrative practices and modalities are hard-won.

This is not the first time I have heard a naturopathic doctor urge would-be "integrative" MDs to take the final two years of a naturopathic medical program or to state that ultimate reform will have conventional MDs as specialists. Practically speaking, both of these desires are forms of suppressed screams, with Liza Minelli, from under the bridge. Or, in Winterstein's framing, from the back of the bus.

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