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Reader Response: CAM/Integrative Modalities/Disciplines in Primary Care in 2025 PDF Print E-mail
Written by John Weeks   
Monday, 02 May 2011

Reader Response #1: IAF Project on CAM/Integrative Modalities/Disciplines in Primary Care in 2025 - Comment Period Extended to May 14

Summary: The Institute for Alternative Futures, led by Integrator adviser and futurist Clem Bezold, PhD, received a grant from the Kresge Foundation to forecast the future of primary care in 2025. One area of interest is the role of "CAM"/integrative modalities/disciplines in that future. The Integrator sent an alert calling for comments and perspectives based on a current "forecast #15" and a set of questions. Here are early responses from Chuck Simpson, DC, Victor Sierpina, MD, Lou Sportelli, DC, David Rakel, MD, Jim Winterstein, DC, and spa blogger Sara Firman, LMT. Responses will be accepted  by IAF until May 14, 2011. Be nice to hear from you and run a second Integrator forum on this topic. 

Priority Response: Send your comments to the Institute for Alternative Futures
via Yasemin Arikan.  
to help shape the report.

Second Priority ResponseSend your comments to
for inclusion in an Integrator forum on the topic.

Comments due (extended) by May 14, 2011

________________________________________________

"In the year, 2025
If primary care is still alive
We may find ..."



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Futurist Clement Bezold, PhD
An Integrator Alert on April 25, 2011 urged
the integrative healthcare community readers to respond to the Institute for Alternative Futures (IAF) call for input on the role of "CAM"/integrative medicine modalities/disciplines in the future of primary care. The study, led by futurist Clem Bezold, PhD, an Integrator adviser, is possible through a grant from the influential Kresge Foundation. IAF is examining the "likely and preferred futures" for primary care in the year 2025.  Below is some initial response. Please share any additional perspectives. IAF's comment period has been extended until May 14.

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Chuck Simpson, DC
1. Chuck Simpson, DC: "Licensed CAM practitioners at the top of their license fit ..."


Chuck Simpson, DC is vice president and medical director of The CHP Group in Portland, Oregon. The firm manages covered benefits for "CAM" practitioners for Kaiser Northwest Permanente and other clients in a multi-state region.  An Integrator feature on CHP from 2007 is reported here. 
[Simpson's comments) In reading over the "Forecasts For Specific Aspects of Primary Care," it is evident to me that licensed CAM practitioners practicing at the "top" of their license fit very nicely into achieving the vision for Primary Care that is set out in these specific aspects.  Without going on at length, consider briefly a few:
 
3. Focus on primary prevention. Truly preventive care is a hallmark of many CAM practices.  And not just the "prevention" as conceived in the conventional medical model, i.e. early detection and medical management (e.g. pre-hypertension, pre-diabetes).

4.  Continuously improving health. CAM care is multidimensional incorporating a holistic view of the patient physically, behaviorally, spiritually.  Holism is a the center of CAM. 

5. CAM practitioners as "relational agents" are right on.  It is well known that the relationship between care giver and patient is a critical element in the success of the "therapy."

8. Quality and Safety Focus. CAM care in a proper therapeutic hierarchy is inherently much safer (and therefore of higher quality) than most conventional medicine interventions for the management of chronic conditions. Medication of course works well in the acute case, short run.  Long term medical intervention bears an often unnecessary and increasing clinical risk and diminishing clinical returns.

14.  Person Centered Care.  See above. CAM practice places the patient in the center of the therapeutic encounter.  Management strategies are respectful of the individual patient's needs, preferences and uniqueness.

In all, CAM care from licensed providers practicing at the top of their license have much to contribute to achieving the "triple aims" in health care. To overlook the fundamental role that CAM clinicians can accomplish is to the detriment of us all.

Charles A. Simpson, DC DABCO
Medical Director, Vice President
The CHP Group
Beaverton, OR  97008
Comment: Simpson's litany is useful in that few mainstream primary care planners honor the contributions and even the leadership of licensed "CAM" practitioners and integrative MDs in areas such as "primary prevention" and "patient-centered care" and "safety." Simpson's reference to the therapeutic hierarchy is particularly apropos. If I was to suggest a single principal to guide a "preferred future" for primary care it would be that investment follows such a therapeutic order in which we first focus real resources on primary prevention, education and empowerment.


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Michael Traub, ND
2.  Michael Traub, ND: Keep a focus on providers in CAM/IM section


Michael Traub, N D, DHANP, CCH, FABNO is a long-term practitioner on the Big Island of Hawai'i. He played a significant role in bringing "CAM" into North Hawai'i Community Hospital. Traub is a former president of the American Association of Naturopathic Physicians. He sent this single edit to IAF's proposed forecast #15.
15.  Integrative encounters in primary care - Integrative encounters address all dimensions of health by bringing the knowledge of conventional, unconventional, complementary, alternative, traditional and integrative medicine disciplines (add here:  "and providers") to bear across the many different cultural traditions of persons cared for.  
Comment: One would hope that "disciplines" would catch the concept of "providers." But given the tendency of mainstream medicine to objectify other disciplines as "modalities," it's worth restating explicitly that we're talking about human beings.


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Vic Sierpina, MD
3. Victor Sierpina, MD: The changes will take place more rapidly ... 


Victoria Sierpina, MD, ABFM, ABIHM is the
Laura Nell Nicholson Family Professor of Integrative Medicine Professor at the University of Texas Medical Branch Galveston, Texas. He is a past-chair of the Consortium of Academic Health Centers for Integrative Medicine. Sierpina wrote:
Extremely well thought out and written. Have forwarded to all our leadership and family medicine people at the University of Texas Medical Branch in Galveston.

My only comment is that this is all likely to occur in much less, perhaps 1/2 the time predicted. I hope I am forecasting correctly.
 
Victor S. Sierpina, MD, ABFM, ABIHM

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Lou Sportelli, DC
4.  Lou Sportelli, DC: "The 'how' will depend on how far we go from a disease model"


Lou Sportelli, DC is the president of NCMIC Group, the nation's leading provider of malpractice insurance for chiropractors and naturopathic doctors. Sportelli first began his practice over 4 decades ago. He served for many years on the board of his local hospital in Pennsylvania, a pioneer in such a position as a chiropractor. NCMIC was the Integrator's founding sponsor. Sportelli begins by restating forecast #15
15.  Integrative encounters in primary care - Integrative encounters address all dimensions of health by bringing the knowledge of conventional, unconventional, complementary, alternative, traditional and integrative medicine disciplines to bear across the many different cultural traditions of persons cared for. 

Bezold and IAF request the following:

Do you have comments on this forecast? The forecast is optimistic that in 15 years, maybe 25 or more we'll begin to incorporate the concepts of all the dimensions discussed above. The ingrained reluctance of the establishment to change is enormous. Additionally the unwillingness of the general public to change or to wean away from the concept of a "silver bullet" or silver pill to solve all problems will cause the time frame to be extended.

Do you recommend an amended or alternative forecast? This forecast is going to be as mandated as any public policy ever has. However just as self-serve is the new normal (remember when clerks actually waited on you and service station workers pumped your gas) the incentives not to participate in the new forecast will be as rare as a smoking permitted establishment. Why? Because the pain of non compliance will be too great and hopefully the evidence for the benefits will be obvious.

Do you have data or insight on a forecasts for CAM practitioners doing primary care, or being on the primary care team?  It will be impossible simply from a numerical point of view not to include all of the above listed providers as purveyors of primary care.  Too many people needing care, too few "medical providers" and a shift in desire to a new paradigm.

Do you have forecasts for how CAM/IM practitioners will be providing primary care as part of teams in community health centers?  Not certain I understand the question?  The HOW will depend on how far from the disease management model we go and toward the health consciousness model.

Do you have any forecasts for growth in numbers of CAM/IM practitioners who will be practice in primary care roles or on teams?  There will be significant growth if the national health care program recognizes that the only way to care for the numbers of people in the system will be to re-shift priorities and focus on improving healthy living and re-educate the providers and consumers on what needs to be done to achieve these goals. There is no incentive to be healthy today. When that realization is finally reached, it is usually too late to do anything about it.

Bezold adds: "Most of the feedback to the CAM question I am getting in the focused groups from conventional primary care folks is that they will include use of the modalities as they are proven effective/cost effective. Any forecasts on the evidence on behalf of CAM modalities and/or CAM licensed providers would be welcome."

This is precisely the problem. Conventional primary folks think CAM is another "ornament on the medical Christmas tree" and not an entirely new way to approach health versus disease.  Until that paradigm shift is fully understood there will be the continued same old approach by the providers and the consumers. The unhealthy burger & fries...but make sure you serve a "diet coke" as if that makes it all right. 

The changes that need to take place need to begin with a total transformation in thinking.  Not too many years ago, computer technology caused a new way of thinking. There was however a bit of reluctance or possibly anger when the programs changed or the upgrades caused disruption in the way things were done: from DOS to windows to Cloud to ? Today however when someone buys a cell phone they expect that it will be obsolete in 6 months and if it is not, something is wrong with the technology or the company's innovation. That same kind of shift in thinking is going to be necessary - from unhealthy to healthy, from drugs to hugs, from fat to fit, from a pill for every ill to - why did I get sick to begin with.  The entire nation should strive to do what we did with Kennedy's pledge to put a man on the moon by the end of the decade. We need to have a national effort to RE-MAKE AMERICA IN THE IMAGE OF A HEALTHY NATION. It can be done, it just takes will and commitment, desire and determination.

Lou Sportelli, DC, President
NCMIC Group
Comment: The likelihood of such a national effort is contained and diminished by Sportelli's earlier observation that most of conventional medicine still views "CAM" as "ornaments on a Christmas tree." In fact, "alternative medicine" and now "integrative medicine" are the release valve for a public that couldn't find health in healthcare. If that energy can be empowered and brought back into this the system, there just may be some popular will to juice up a national campaign.


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David Rakel, MD
5. David Rakel, MD: "I simply agree with Clem and ..."


Two years ago i worked with David Rakel, MD on a medical home-related project that lead to a presentation at the North American Research Conference on Complementary and Integrative Medicine. I specifically asked Rakel, who heads up integrative medicine at the University of Wisconsin, for his perspective. He wrote:
"I thought about what I could write, but I simply agree with Clem. He has a well-polished crystal ball (I hope!)."
Comment:  I thought it worth including Rakel's comment, merely to capture the agreement. Notably, both Rakel and Sierpina felt the need to note their "hope" that the forecast would come to be. Regarding Bezold's crystal ball: it is indeed well-polished. Bezold founded IAF with futurist Alvin Toffler back in the day when a role of a futurist in planning was, well, only valued by budding futurists. In my first connection with Bezold, he taught me a self-protective quality of the crystal ball of the schooled futurists. It bounces, as with the primary care 2025 study, between "preferred" and "likely" futures. For ideas on how to engender the former, see Sportelli, above.


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Jim Winterstein, DC
6: Jim Winterstein, DC: "I would love to see (forecast #15) come true ..."


Jim Winterstein, DC is president of the multidisciplinary National University of Health Sciences. The chiropractic program at NUHS is known for focusing on educating broad-scope chiropractic physicians. He is a board member of AMI Group, a firm that found significant cost savings from integrative practice by whole-person oriented chiropractic doctors. He references the studies below.
15.   Integrative encounters in primary care - Integrative encounters address  all dimensions of health by bringing the knowledge of conventional,  unconventional, complementary, alternative, traditional and integrative  medicine disciplines to bear across the many different cultural traditions of  persons cared for. 

Do  you have comments on this forecast?
  This, in my opinion, is highly optimistic. Whether I like it or not, the American public, with all of the recent interest in alternative forms of health care, still seeks the almighty "magic potion." They visit their chiropractor, or massage therapist, or naturopath or whomever. But when they think they are "really sick," they want their MD. This has occurred in large measure because the allopathic profession has been very successful in promoting the position that they are the only ones with the knowledge necessary for public health, even though the statistics say otherwise.

I would LOVE to see this statement become true, so I suggest all involved think about how to promote it.

Do  you recommend an amended or alternative forecast?  There is SOME light at the end of the tunnel. Someone recently commented that the amount of the NIH budget committed to CAM research is "homeopathic" in its quantity. It is about 1% of the total, I believe. Well at least there is some. But unless we can get a stronger and unassailable commitment (the allopathic community must be kept out of the cookie jar that is mandated for CAM research) from NIH, it will be difficult to see this forecast coming true. I would like a forecast that says something like:
 "Integrative encounters in primary care - Integrative encounters that address all dimensions of health by bringing the knowledge of conventional, unconventional, complementary, alternative, traditional and integrative medicine disciplines to bear across the many different cultural traditions of persons cared for, will be mandated by Health and Human Services without allowance for professional 'turfism.'"
Do  you have data or insight on a forecasts for CAM practitioners doing primary  care, or being on the primary care team?  The only actual data that I can reference are the two articles written by Sarnat, Winterstein and (the second one) Cambron. (see attachment), which do reveal that there IS a potential for chiropractic physicians and others to function as primary care providers. A stumbling block to their effectiveness could be a reluctance or refusal of the allopathic profession to accept the CAM provider as a capable PCP with ability to coordinate as defined by the Institute of Medicine. What happens in daily primary care practice in the allopathic office is not what the allopathic profession usually promotes as primary care. It is not an expansive practice because any case of hypertension that goes beyond the realm of one or two medications is automatically referred to the specialist - same for diabetes and for asthma and on and on. What is often missed is the value of the simple lifestyle changes that can be promoted better by the CAM provider, not to mention the value of physiological input as a result of mechanobiologic therapies.

Do  you have forecasts for how CAM/IM practitioners will be providing primary care  as part of teams in community health centers?  CAM providers COULD be participative in the primary care "community health center" arena IF they can gain entrée. Rick Duenas,DC of Connecticut has been working hard on the "Medical Home" concept but continues to experience resistance by the establishment that simply believes that ONLY the MD is in a position to function as the PCP. This, at a time when everyone knows of the deficiency of MD providers in this arena.

CAM providers at the first professional doctoral level MUST be permitted to function as PCPs in these settings. What is happening at MOST integrated clinics of which I am aware, is that the MD "rules" and all else are designated as "allied" providers who are expected to do whatever the allopath decides. The problem with this is that while a DC, for example has been trained at least to some degree in pharmacology (90 hours) and botanical medicine (105 hours) the allopath has almost NO working knowledge of how the chiropractic, naturopathic, or oriental medicine systems of healing, for example actually work. How then can they effectively determine best use.

In my forecast, the CAM provider sees the patient first - provides care as indicated and/or triages and then refers to the allopathic or osteopathic specialist when clinically indicated.

Do  you have any forecasts for growth in numbers of CAM/IM practitioners who will  be practice in primary care roles or on teams?  As you know, at National, we have educated at the primary care level for decades (many decades) BUT the entire system mitigates against its successful practice with the reimbursement agencies simply refusing to pay for primary care treatment in many instances for no good or rational reason - they are "attuned" to the long emphasized allopathic model and changing them is nearly impossible. They, for example do not seem the least bit interested in potential "savings" (see attached) under a CAM PCP model.

With that background, it is difficult to predict growth in numbers of CAM/IM practitioners in the PCP role. I can say that the chiropractic profession is currently in decline.

Do  you have comments related to the other forecasts or different forecasts that  have thus far been overlooked?  Health care in the United States is clearly not what we think it is. My forecast is that the model being currently promoted is not likely to work because it is simply far too expensive. I think a revolt is coming but it is still a decade away, after which, people may well turn to the alternative providers for care that is offered on a cash basis. I just don't think the current model can sustain itself. If there were no third party reimbursement for health care, an MRI would soon cost $150 because MRI equipment and all inflated equipment and test costs would come down. It is a matter of how markets work. We already know that pharmaceutical costs are grossly inflated - mark ups sometimes being in the area of 1000 percent or more. All just "speculative wishing," but I remember different days when people actually paid for their health care costs (which also gave them a "dog in the game") and doctors still made a good living and were probably at the upper levels of income. I know, I am getting way out there.....:-)

Do  you have comments or forecasts on the nature of CAM modalities in primary care  in 2025? So little is known about "mechanobiology," (see attached) the effect on the body produced by mechanical forces - from needle insertions, to hydrotherapy, to massage, to articular manipulation etc., but the knowledge base is growing and IF the CAM professions begin to take notice and contribute to the research, we could see significant outcomes, I believe. Further, there is no doubt in my mind that the CAM providers are better equipped to promote lifestyle change - nutrition, exercise, relaxation, stretching, stress reduction, weight reduction etc., BECAUSE they are not seen as practitioners who offer a "pill for everything."

Bezold  adds: "Most  of the feedback to the CAM question I am getting in the focused groups from  conventional primary care folks is that they will include use of the modalities as they are proven effective/cost effective. Any forecasts on the  evidence on behalf of CAM modalities and/or CAM licensed providers would be  welcome." 
In typical fashion, the "gods of health care delivery and patient protection" see what anyone else does as "potentially useful tools" that they can "get some technician" to use if the allopath believes it might be useful. Ironically, they want to talk about "cost effectiveness?" What a novel idea! What about allopathic medicine brings to mind the term "cost effective?" It is a ludicrous concept in the extreme! It is a concept that drives the chiropractic physician to drink every time he/she "fixes" someone's back pain for 300 bucks when the patient's orthopedist, after a referral from the PCP has told the patient that surgery is essential and no one even mentions the cost because it is automatically picked up by the third party payer - billed at $75,000 and paid at $45,000 (another farce)! Don't get me started Clem!

I think it is essential to recognize that unless the public in general and the federal legislature in particular come to the decision that allopathic medicine is NOT the keeper of all health care knowledge and is NOT the "god mandated" protector of the public health, the real potential value of different "systems of healing" will never be recognized as such simply because they are not part of allopathy. That is "sinful" but true. Walk in to any gathering and simply get on the PA system and say "doctor!" What comes to mind in the vast majority of the people at the gathering. I'll wager it is not PhD, not, DDS, not DC, not ND, not DPM, and not even DO. It is MD - their PR machine, in concert with the legislature and the legal profession, has so totally brainwashed the public that making any kind of real change is extremely difficult. Meanwhile, every "piece" of the CAM professions that show scientific promise will be taken and used in some manner by the allopaths. Meanwhile, the "concepts of healing" that are part and parcel of the CAM professions will be discarded and lost.

Thanks. My rant is now over.

Jim Winterstein, DC, President
National University of Health Sciences
Comment: Bleak view, expressed here. I am often hard-pressed to argue with Winterstein's perspective. That being said, a call for a doctor on a PA system will likely be for an emergency, which is where conventional medicine excels. There is however a growing number of people who, when they have something going on that doesn't feel good, will look to themselves or to one of the other forms of "doctor" (including an integrative MD), for how to deal with the issue. Gross numbers partly circumscribe the effect of these other types of doctors: there just aren't that many broad-scope, primary care-oriented DCs, NDs (in total), AOM practitioners who assume a primary care level of responsibility and patient management, or even of integrative MDs or holistic nurses. Just play the numbers game and it becomes clear that any preferred future for primary care 2025 will be one in which the vast majority of primary care MDs and advanced practice nurses approach care from a profoundly integrative perspective, such s is expressed forecast #15. 

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Sara Firmin, LMT
7.  Sara Firman: Cross-fertilizing with the future of wellness and the Spa industry


Sara Firman, BSc. MPhil. LMT is an independent spa therapist, consultant and writer. She writes on spa culture on her weblog Vision Spa Retreat. She has worked in clinical, spa and private settings as both therapist and manager in the UK, Israel and the US. She shares that she currently resides in the middle of an Ozark forest with a river running through it in southern Missouri. She first sent the Alert to "CAM practitioners in my circle" then sent the following to IAF.
Through The Integrator Blog, I have just come across your work in progress designed to shape future policy for Primary Care in 2025.  I think it is truly visionary and very heartening to read.

I am an independent commentator on the spa industry and have just posted something on my blog about the explorations in progress of the role spa might play in a healthy future.

It includes at the end a mention of IAF, as I am sure your organization would have valuable insights to add to a debate about the role of spa in health and wellness provision.  

My post (May 2, 2011) on Vision Spa Retreat: Wellness and the Spa: paradigm shift or marketing move?

With sincere interest in furthering good health care for all,

Sara Firman

Vision Spa Retreat
Comment: A deep experience of something like wellness seems to be a necessary light for many if they are to move out of the tunnel of habitually living with harmful choices. Spa services are definitely on my "preferred future" list. I haven't yet heard the medical intelligencia behind the Accountable Care Organization promoting such services, meaning hard money won't likely be betting on these as "likely futures" category. The moonshot mentality that is recommended by Sportelli would definitely be exploring spa use. 
 
Send your comments on Primary Care 2025
for inclusion in a future Integrator forum.



Last Updated ( Thursday, 05 May 2011 )
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