Reader Forum: Manahan, Kahn, Foley, Winterstein, Bolles, Levin, Olejownik, Fonfa, Sabin, Rohleder, Keating

Summary: Correction: Dr. Roger Rogers after whom the Dr. Rogers Prize is named is alive ... Bill Manahan, MD on pain treatment, CAM and the IOM pain blueprint ... Janet Kahn, PhD on key Integrated Healthcare Policy Consortium language in the National Prevention Strategy ... Ann Fonfa comments on sham acupuncture in the IOM blueprint ... Jean Keating, PharmD speaks up for independent pharmacists ... Glenn Sabin offers an informed patient's view on Freedman's Atlantic article  ... Jim Winterstein, DC speaks to a value in the term "alternative medicine" ... Jennifer Olejownik, PhD on the current state of integration ... Chris Foley, MD and Stephen Bolles, DC on "patient-centered care" and "code-centered care" ... Michael Levin of Health Business Strategies on the characteristics of Primary Care 2025 ... Lon Jones, DO and Common Sense Medicine weigh in on the future of primary care ... Lisa Rohleder, LAc offers a useful rant against protective guild behavior ...

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Namesake Roger Rogers, MD is alive

1. Correction: Dr. Rogers of the Dr. Rogers Prize is Alive and Well!

In a recent Integrator Round-up (since corrected) I stated that Roger Rogers, BA, BSW, MD, OBC after whom Canada's Dr. Rogers Prize for integrative health was named, was deceased. He is alive. My apologies to Dr. Rogers and his family.  Meantime, the 2011 Dr. Rogers Prize event, funded through the John and Lotte Hecht Foundation, will be in Vancouver, BC on September 23, 2011.

Bill Manahan, MD

2. Bill Manahan, MD: Failure to provide CAM to pain patients is one of medicine's most unfortunate practices

Integrator adviser Bill Manahan, MD responded to the Integrator Resource: Inclusion of IM/CAM in  the IOM Pain Blueprint. Manahan is a Minnesota-based, long-time leader in holistic and integrative medicine. He was particularly struck, in that article's comment field, by an unattributed remark questioning how new the IOM perspective is.

"I agree with this statement regarding the pain blueprint:

I hate to say it but the document does not really say all that much. They just can't get their collective mind around the fact that much of the treatment and management of pain requires good hands and a good exam, and that most docs are simply afraid of pain. Thus, they seize up and default to prescriptions and referrals.

"My take on this - as an M.D. - is that allopathic medicine practitioners are, in general, incredibly uninformed about almost any types of treatments beyond pharmaceuticals for helping in pain management. The treatment of pain is similar to how we allopaths treat most chronic problems. Our pharmaceuticals are often very good for treating the acute pain problems but frequently not very helpful for managing chronic pain.  This is similar to how our pharmaceuticals are great for infections and many other acute, single factor problems.  But when we try to use pharmaceuticals for osteoporosis, arthritis, type 2 diabetes, heart disease, chronic musculoskeletal problems, gastroesophageal reflux, and other chronic complex problems, we are often doing our patients a real disservice.
 
"Why would we not use less expensive, safer types of treatments before going to pharmaceuticals (especially narcotics) for treatment?  Hypnotherapy, yoga, massage, exercise, osteopathic manipulation, structural integration, Qigong, Reiki, healing touch, meditation, guided imagery, sound therapy, acupuncture, biofeedback, and a host of mind/body therapies could be SO helpful to so many people with pain.  I believe that the lack of patients being prescribed CAM therapies for pain is truly one of the most unfortunate practices we have occurring in healthcare today.  Many people are suffering needlessly because of the reluctance of medical doctors to learn a broader approach to pain management."
 
Bill Manahan, MD

3.  Janet Kahn, PhD: National Prevention Strategy used IHPC language to define "integrated health care"

Janet Kahn, PhD, the executive director of the Integrated Healthcare Policy Consortium recognized something familiar in the language about CAM/IM shared in the

"Thanks for your summaries.  Life has been busy and I have not yet read the Prevention Strategy, but I will now, as your quotes from it included a 'quote' of sorts from IHPC. Their definition of integrative healthcare in the opening line of what you lifted from their page 22 sounded so familiar I went and reread what we had submitted to the Surgeon General. Turns out it was word for word. See attached. SO thanks for a first thing in the morning reminder that there is some traction being gained."

"As you may be aware, IHPC is a broad coalition of clinicians, patients, healthcare educators and organizations committed to public policy that ensures all Americans access to safe, high quality healthcare, including the full range of qualified conventional, complementary and alternative healthcare professionals.  Integrated health care describes a coordinated system in which healthcare professionals are educated about one another's work and collaborate with one another, and with their patients, to achieve optimal well-being for the patient. Integrated healthcare, of course, provides for the population's full health needs from primary prevention through acute illness and trauma care to palliation and compassionate end of life care. Its hallmarks, however, are a focus on health promotion and patient engagement through strong relational care." [bold added)

Ann Fonfa

4.  Consumer advocate Ann Fonfa: IOM is right to say sham is inappropriate acupuncture control

Ann Fonfa is a long-time organizer and advocate for healthcare choice. She writes

"Lots of interesting tidbits in this information, thanks for gathering it.  I am concerned, as I have been for years, about sham acupuncture.  In this report it is used to point to acupuncture being no more effective than sham.  Has anyone looked at brain function (MRI) to compare sham to correct acupuncture?  I agree with the bolded section from NIH below, that sham is not really ineffective and thus not an appropriate comparison.  My interest is in treatments for those with cancer, or preventive methods.  Ann F.

NIH stated:  "A commonly used control group is sham acupuncture, using techniques that are not intended to stimulate known acupuncture points. However, there is disagreement on correct needle placement. Also, particularly in the studies on pain, sham acupuncture often seems to have either intermediate effects between the placebo and 'real' acupuncture points or effects similar to those of the 'real' acupuncture points. Placement of a needle in any position elicits a biological response that complicates the interpretation of studies involving sham acupuncture. Thus, there is substantial controversy over the use of sham acupuncture in control groups. This may be less of a problem in studies not involving pain".

"Research on acupuncture has been controversial. Of interest, a systematic review of 23 clinical trials found moderate evidence that acupuncture and sham acupuncture are, in roughly equal measure, more effective than no treatment for chronic low back pain (Yuan et al., 2008). This finding is consistent with evidence from a rigorous German study (Haake et al., 2007). The success of sham acupuncture, in which needles are inserted in the body but not at acupuncture points and usually not with stimulation, has led to debates among researchers and clinicians about the value of placebos (Berman et al., 2010) (see the next section). Some critics of studies finding a lack of efficacy for acupuncture contend that the study findings are based only on criteria of Western medicine, not those of traditional Chinese medicine (Chiang et al., 2010)".

Glenn Sabin

5.  Glenn Sabin: Patient's perspective on "The Triumph of New Age Medicine"

Comment: Self-described cancer "thriver," integrative center consultant and new Integrator adviser Glenn Sabin sent a note following the Integrator article

Jim Winterstein, DC

6.  Jim Winterstein, DC: Reclaiming "alternative medicine"

Jim Winterstein, DC, president of National University of Health Sciences read the articles on Freeman's Atlantic piece and sent an email in which he used one of my comments as his subject line: "Maybe it's time to reclaim 'alternative medicine'?" Freedman chose to use "alternative medicine" repeatedly. Winterstein, a regular contributor, wrote:

"I liked your comment [in the subject line]. Personally, I never had a problem with the term 'alternative medicine,' because it is an a priori assumption - it makes sense. There are times when the best 'alternative' for a patient is the allopath, times when the best alternative is the naturopath, and times when it should be the chiropractor, or the acupuncturist etc. etc.

"The real 'crux' here is that the allopath NEVER sees him/her self as the 'alternative' but rather as the 'only choice' for the patient. The terms 'complementary medicine' and 'integrative medicine' are allopathic efforts to include what they know the public is seeking without conferring the associated practice authority to those of the so-called CAM professions. "We can integrate them and allow them to 'complement what we do,'" - but the reverse is never true!

"Some members of the chiropractic profession did not and do not like the term 'alternative medicine' because they believe it automatically casts them as 'outside the norm,' but if all of us could accept that we are 'all alternative' depending upon the needs of the patient, then we would all be ok! It is no different than saying 'what is the best choice in this instance?' If we truly want to place the patient at the center of all our efforts and intentions, then we are 'all alternative.'"

Jim Winterstein, DC, President
National University of Health Sciences

Jennifer Olejownik, PhD

7.  Jennifer Olejownik, PhD: Communication and collaboration are barriers

"Since the early 1990s biomedicine's relationship with CAM has passed through several phases from condemnation to reassessment to integration. 

"Although we are currently in an integration phase, much effort has focused on exploring the efficacy of CAM practices and procedures.  While scholarship of this kind elicits useful information for the medical profession, little research has been conducted on the process of integration that privileges the perspective of CAM practitioners working in integrative environments. 

"From the scarce research that has been conducted on integration, it is evident that communication and collaboration are two of the biggest barriers thwarting the integrative process. 

"From my own experience launching an investigation into this arena, there has been very limited research exploring how conflicting healing philosophies affect the operative practice of CAM in an integrative environment.  Given that a paradigm clash exists between biomedicine and CAM, as Ian Coulter describes, it seems that both sets of practitioners need to negotiate, or at least dialogue, their healing philosophy for the sake of integration. 

"In the applied sense, what does each group gain and/or lose in the process of integrating?  How do these divergent practices blend together?  What are the philosophical and paradigmatic tensions practitioners negotiate as these processes unfold?  Is the dominant medical model being reinforced or is something new emerging as a result of this newly forged dialogue? 

"Findings from the field seem to indicate that while the US is moving back toward a more pluralistic model of medicine, it is doing so in a very superficial manner since the voices of CAM practitioners appear to be marginalized both in theory and in practice." 

Lisa Rohleder, LAc

8.  Lisa Rohleder, LAc: A welcome rant against turf wars and why they are, quaintly, "sinful"

"So from the perspective of the real world of acupuncture practice, these arguments are laughable. But making them in this way isn't funny, because it's also just wrong. Immoral. I know I'm quaint in this regard, but I'm going to revert back to my working class Catholic upbringing and say that turf warfare is a sin. Because that's what I really think about it. That's the summary, soup to nuts, I don't care if we're talking about PTs or DCs or MDs, it's all BS. And it's a sin. For those of you who managed to avoid years of CCD (that's what they called Catholic Sunday school when I was a kid, only it wasn't on Sunday), sins are sins because they harm your relationship with God, your relationship with others, and your relationship with yourself. I'm going to leave God out of it, but the other two categories do apply here ... Turf warfare doesn't just harm our relationship with others, it harms others, period."  

Chris Foley, MD

9.  Exchange between Chris Foley, MD and Stephen Bolles, DC on "code-centered care"

Chris Foley, MD is an integrative medicine doctor who runs the clinic Minnesota Natural Medicine. Foley began one of the nation's first health system-based integrative clinics. He has more than once expressed his opposition to any affirmative engagement with the current payment system. Foley writes in response to an Integrator column from Stephen Bolles, DC entitled 

"But Steve gets one thing right: The 'Patient Centeredness' BS we hear from mainstream folks is just that. The Medical Home is something I built more than 11 years ago, but I threw out the coding system.  IOWs, the currency is what REAL marketplace currency is: time and money.  I give away some extra time, but patients agree to certain fees that are non negotiable.  It works, we are busy, and I suffer very little interference from IOM type of corruption.  If Steve were really harmonic with the 'marketplace', he would understand that the ICD9, CPT, and DSM matrix entangles care to a point where it cannot possibly be 'patient centered'.  It is absolutely 'code-centered', and no amount of philanthropic/academic adoption will ever get past that. I can't wait to go to the office every day."

Stephen Bolles, DC

I sent Foley's comment to Stephen Bolles, DC to see if he had a reply. Bolles, a former vice president at Northwestern Health Sciences University who also played a major role in some early integrative clinic developments in the Twin Cities, responded:

"Chris was certainly a pioneer in understanding that group-delivered care had some real benefits in terms of patient engagement, and had appealing aspects as a business model, too. It's unfortunate he did not get support for the model from the system he was part of at the time, but he has continued to be a pioneer.

"My lack of condemnation of the current coding system may or may not be evidence of 'harmonic dissonance.' I simply didn't cite the issue, but Chris is absolutely right: the current coding system is part of the problem. It forces providers to reduce the complexity of a patient/consumer encounter--whether or not they see that complexity as important to acknowledge or embrace--to a very one-dimensional representation of an individual. It's simply not defensible.

"It may not still be true, but one of the more startling revelations to me while working at UnitedHealth was that their data system was often only set up to capture one diagnosis coding field. One. So no additional codes for anything resembling a context for the primary diagnosis was even captured, let alone appreciated. So the coding system is fundamentally inadequate and flawed--even for its minimal utility in compensating providers for transactions.

"And even with that, quite a bit more could be challenged, critiqued and condemned. But my comments were aligned with how you portrayed the trends."

Stephen Bolles, DC

Sara Firman

10.  Sara Firmin: Regarding integrative health, karass, granfalloon and Vonnegut

Spa-blogger Sara Firmin operates a site she calls Vision Spa Retreat: Reflections on Spa, Soul and the role of Water. She responded to the Integrator column in which I reflected on Kurt Vonnegut's distinction between true community (karass) and false community (granfalloon).

"I found your post around the question of 'karass' or 'granfalloon' very thought-provoking - I have not read Vonneguts's Cat's Cradle but shall now.  Perhaps the clue is to be found in true community being formed 'often unknowingly'.  How can we say what is 'cosmically significant' or 'spiritual destiny'? And when something dies (like your CHRF) can we say it failed or that it served its purpose along the way? How we see all this might indicate what we think 'health' really is.

"I live in a 1000 acre forest which at first glance seems to be defined by the trees but recently I learned that the trees are all connected underground by a web of mycorhizae (fungi) without which they could not live.  Likewise, each of us is populated invisibly by hosts of bacteria without which we could not live.  The ebb and flow of these hidden relationships, in response to environmental stresses, leads to varying visible states of health.

"In Flow (The Anatomy of Consciousness), Csikszentmihalyi suggests that, as regards human consciousness, 'The shape and content of life depend on how attention has been used.  Entirely different realities will emerge depending on how it is invested....'  This suggests to me that the shift from 'granfalloon' to 'karass' will come when we truly understand 'health' as a dynamic and complex process rather than fixed and distinct event.

"I suspect that our best teacher and model will be the natural world. Csikszentmihalyi went on to say that 'Traditional Melanesian sailors can be taken blindfolded to any point of the ocean within a radius of several hundred miles from their island home and, if allowed to float for a few minutes in the sea, are able to recognize a spot by the feel of the currents on their bodies....' That level of atunement could be applied in all settings but is lost on most of us.

"'Because attention determines what will or will not appear in consciousness ... it is useful to think of it as psychic energy.'  Attention is like energy .... We create ourselves by how we use it.' So, perhaps the contemplation Vonnegut and now you and your friends have raised about what creates real and healthy/healing community is a good place to focus our attention. A shamanic practitioner introduced me to the idea that healing can include dying, life and death together.

"Through my interest in the spa world (which you do not mention in your post but which as an 'industry' is become very interested in organized integrative 'corporate health care') I notice that even as all things natural are celebrated, there remains the anxious drive to live forever, never aging. Rarely is it asked what purpose and part natural decline plays in the cycle of life.  'Karass' it seems to me is about our humanity, while 'granfalloon' describes our hubris.

Thanks again for making me think about my own perspective on what integrative community is or could be.

Sincerely, Sara Firman
Vision Spa Retreat

Michael Levin

11.  Michael Levin: Comments on  Primary Care 2025

"Overall Comment: Changing demographics, morbidity trends, technology and economics will drive changes in primary care delivery & focus. These will combine to focus and reward prevention, rather than treatment, in an effort to reduce national healthcare costs by improving the public health. This is both a preferred and likely future, primarily driven by economic imperative.

"1. Payment Form & Primary Care: Comment: Conspicuous in its absence are shared-risk components of the integrated and semi-integrated payment schemes. Under shared-risk arrangements, payer networks contract for population-specific outcome goals over a long time period, during which payments are made based under negotiated benchmarks. If benchmarks are favorably exceeded thus reducing the longitudinal planned costs of care, the increased savings are shared by an between all stakeholders. This incentivizes patient, practitioner and administrator alike to exceed outcome expectations. This is a preferred future and, if carefully constructed, a likely future, as it improves public health while lowering costs. A win-win-win."

Forecasts for Specific Aspects of Primary Care 2025

"7: Focus on Behavioral Change  I've slogged through the healthcare cost-containment world since the phrase first emerged in the mid-70s. I'll language this comment as a separate forecast, to elevate it's criticality:

"Forecast: Economic rewards and punishments will be effectively used to create healthy lifestyle and behavior changes. Recognizing that the most common drivers of disease are lifestyle choices, behavior change programs will be integrated with primary care delivery. Home biometric monitoring, web-mediated coaching, and the use of economics to encouragement engagement will be the norm, not the exception. Consumers will become painfully educated about the costs of their misbehavior to society. The days of "fish and loaves" for disease treatment ("fix me doc, at whatever cost, even though I did this to myself") will end. An era of personal accountability will begin."

"11. Precision Medicine: Again, conspicuous in its absence is the impact interactive technology will have on primary care, in terms of both locus and types of intervention. Maybe I missed something. My point is this: we already have remote technologies in place that reduce costs of anticoagulation therapy (coumadin) through which INR measurements are transmitted to a doc who titrates the dose of coumadin which is automatically dispensed at the patients home thru robotic delivery devices, thus assuring medication compliance while relieving the costs of patient clinic visits. In the future, we will have a broad array of at-home, low-cost, diagnostic technologies that will empower primary care folks with the ability to better manage chronic diseases at far lower costs. Asthma, diabetes, anticoagulant therapy, IV antibiotic therapy and (yes) sleep apnea quickly come to mind as high-cost, high-impact areas for remote management. These types of cases will be managed by primary care practitioners (be they PAs, RNs, NDs, RPhs) and referred upwards to specialists only on an as-needed basis. Doing so gets "under the costs" in several meaningful ways. And driving engagement with remote, internet-mediated technology tools using economic incentives will clearly reduce costs while improving outcomes in several major ways.

"15. Integrative Medicine: As QOL measures and longitudinal economic outcome measures accrue and mature, the role for integrative medicine will become increasingly valued and embraced. In particular, the role of nutritional medicine will expand at the expense of Pharma. The economic arguments for the use of nutritional supplements & lifestyle changes first, before drugs, will become so compelling as to change FDA claims restrictions regarding dietary supplements, just as the laws for generic drugs were passed over the strong objections of Pharma in the 80s (see niacin, st johns wort and fish oil as economic examples that can, on an annualized basis, reduce annualized and growing direct drug spending by $1-2B/year)."

Michael Levin
Health Business Strategies
PMB 585
12042 SE Sunnyside Road
Clackamas, OR  97015
503-753-3568 (direct)

Lon Jones, DO and partner Jerry Bozeman

12.  Lon Jones, DO: Common Sense Medicine should guide primary care

Integrator reader Lon Jones, DO is an advocate for what he and his partner Jerry Bozeman call Common Sense Medicine. Like Levin, he wrote in response to the call for perspectives on Primary Care 2025. Jones is based in Plainview, Texas.

"Following are my comments on what I would like to see for the future.

"At Common Sense Medicine we see many of the problems in terms of the old paradigm of Humoral medicine upon which our current practices are built. Any time symptoms become the primary focus of therapy we are at risk of practicing humoral medicine. We argue for the need to switch to biological medicine where we ask why symptoms are expressed. The simple answer is that they provide a survival advantage to one side or the other in our ongoing game with the invaders in our environment. If the advantage is ours the symptoms are defenses. Our washing defenses provide the best example: diarrhea washes our GI tract and rhinorrhea our upper respiratory tract; and blocking those defenses, as is currently done with a variety of drugs, is not in our best interest since it robs us of their survival advantage.

"If, on the other hand, the advantage goes to the other side and the symptoms we have actually help the opponent (as in the fever and prostration that make people with malaria easy meals for hungry mosquitoes, or in the profuse watery diarrhea of cholera that spread the bacteria widely) then the symptoms are called manipulations. Defenses need to be honored and supported since they  give us the advantage. Manipulations need to be blocked, most easily with mechanical means like bed nets, good sanitation, and hand washing.

"There are also ways, largely ignored, to assist our defenses. Oral rehydration has a 40 year track record of helping to make our GI  tract's cleaning  safe and effective. The use of xylitol orally has a similar track record in preventing tooth decay and used nasally a 10 year  record of optimizing our nasal defenses.

"Recognizing our defenses would help change our practices; honoring  and supporting them would save millions; optimizing them would save billions. We hope this shift in thinking is a part of our future.

Lon Jones D.O."
Common Sense Medicine

"I read your June blog and wanted to make a comment. I only saw a small reference to pharmacy.  As a pharmacist, I believe that pharmacists should be included in any integrative teams for health and wellness. I work in a family owned independent pharmacy and we are trying to promote health and wellness as an option for patients.

"I agree that patients should be treated more holistically, and a team approach would be a lot more effective.  Medication therapy is a necessary piece of modern healthcare that will never go away, and a pharmacist is the medication expert who carefully and thoughtfully focuses on drugs and their effects and interactions.  No other part of the healthcare team is trained to focus and solve medication issues.

"This is the only blog that I have read, so I'm not sure if you have included pharmacy in the past.  I saw your reference to Jill's list and that is how I came across this article. 

"As an independent pharmacist I am becoming more involved in trying to promote our profession as a valuable health care resource.  Thank you for your time."

Jean Keating, PharmD
Granby Pharmacy, Granby Connecticut