Frustration with Integration: Perspectives of an Academic MD, Winterstein, Sportelli, Anonymous ND
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 theirivory towers for their entire careers, climbing up the 'ladder.'Those in CAM who have tenured positions are generally from among
thesecareerists who jumped on the CAM bandwagon when their own careersin 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 outthey could get up quicker jumping into CAM - which most did not
want totouch back when we all got it started. That means, they will make
sure thatno genuine leaders get 'their' new jobs, let's say
those who wrote the books that everyone now usesconveniently when they create new courses to go with 'their' new
positions- withouthaving 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 thewater. 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 ..."
"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, MDin 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.
