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UC Irvine's Susan Samueli Center for Integrative Medicine: Research-Centered or Patient-Centered? PDF Print E-mail
Written by John Weeks   

UC Irvine's Susan Samueli Center for Integrative Medicine: Research-Centered or Patient-Centered?

Comment: The Susan Samueli Center at UC Irvine is the lesser known, alongside the Samueli Institute, of the 2 major projects in integrative medicine that philanthropists Susan and Henry Samueli have backed. The Center, at UC Irvine, includes a world-leading acupuncture-cardiology research operation, education initiatives and, since 2008, an off campus integrative medicine clinic. This report on the Center is based on interviews with director John Longhurst, MD, PhD, medical director Wadie Najm, MD, MEd and associate director Laurie Macauley. The center is a microcosm of the research-centered or patient-centered duality that, for better and for worse, is at the heart of the evolution of integrative medicine. Here is a report, plus some reflections on the duality.
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ImageRoughly a decade ago, philanthropists Susan and Henry Samueli initiated significant, bi-coastal, investments in complementary and integrative medicine. 

In July of 2001, the Samuelis used their Broadcom fortune to found the Alexandria, Virginia-based Samueli Institute. Selected as CEO was Wayne Jonas, MD, the former NIH Office of Alternative Medicine director. The Institute is arguably the
integrative medicine leader in 3 areas: total fitness in the military, optimal healing environments in hospitals, and whole system planning in national prevention and wellness policy.

(Integrator readers are invited to join the Institute for an evening event October 4, 2011

Less known is the $5.7-million gift the Samueli's first made to the University of California at Irvine, near their home. The 1999 gift, $2-million of which was an endowment, established the Susan Samueli Center for Integrative Medicine. NIH Heart Lung and Blood-funded acupuncture and cardiology mechanism researcher
John Longhurst, MD, PhD was the chosen as director.

Image
Philanthropist Susan Samueli and director John Longhurst, MD, PhD
I first connected with the Center in 2006. The Center now includes educational programs and a clinical offering. I interviewed a staff acupuncturist for a project on competencies of licensed acupuncturists in integrated environments. In the process, I learned of a Longhurst's work. Mechanism research was clearly the most significant of the Center's activities. 

In the ensuing half-decade, the Susan Samueli Center expanded.
Clinical and educational offerings have grown. Longhurst and his team continue their world-renown research. They argue that their evidence shows that meridians work as nervous system overlays.

I recently conducted 3 separate interview, one with Longhurst and the others with the Center's medical director Wadie Najm, MD, MEd, and associate director Laurie Macauley. I then wove these into the interview and chart below. Their diverse perspectives and orientations capture the sometimes challenging tensions between patient-centered and research-centered integrative medicine efforts.

One place where all three are in agreement: something has shifted
for integrative care at UC Irvine. Opportunities are opening. Here are elements of the interviews, in a combined format. An At a Glance chart is below, followed by some commentary.
________________________________

How the doctors came to integrative medicine

Integrator: How did you get involved in complementary, alternative and integrative medicine?

Longhurst: I'm very much a traditional MD, an internist cardiologist. 100% of my career is in academic medicine. If I learned about alternative medicine in school it was a course on quackery in medicine. A visit to China in the early 1990s led to an invitation by Dr. Peng Li to participate in a research project on acupuncture and chest pain. I was originally opposed then decided to do it. Our research showed that symptoms of angina can go away with acupuncture. We published in 1998 in Circulation, a high-impact journal. Dr. Li is still the major person in our lab.

Image
Wadie Najm, MD: Medical director
Najm
: I am a family doctor with a specialty in geriatrics. I began to be curious about alternative treatments during my
geriatric residency. While visiting people's homes, I was seeing they were using plants and herbs. I got curious and started taking courses so I could talk with my patients. First I was interested in interactions. The more courses I took, I began to take a different view: If this is what they want, how will I work with them and make these work for them? I took the Helms acupuncture course in 1998. Then I started exploring hypnotherapy, supplements and mind-body medicine. The more I learned, the more I practiced. To me, the medicine is a very perpetual learning. For me it is not black and white about whether something is of value. I am more clinical.

Founding as research program

Integrator
: The different origins are interesting, with one of you research-focused, the other's interest begun via geriatric patient home visits. Dr. Longhurst, say a little more about the research with Dr. Li and the rest of your group.


Longhurst: Most acupuncture researchers are looking at pain, not at the cardiovascular influence. My group is the only one in the world doing this kind of work. Our funding is through [NIH] Heart Lung and Blood, not NCCAM. We've had 3 center grants. After the initial research, we began looking at the mechanism for lowering blood pressure. We believe the acupuncture effect is because most meridians overlie neural pathways. If you cut the nerve, you can make the acupuncture effect go away. We've found in both human and animal studies that 70% of each responds to acupuncture. If you apply the needles 30 minutes one time a week for 4-6 weeks the blood pressure goes down and will stay down for 4 weeks after treatment stops, then starts back up. We are now looking at reinforcement treatment. We are looking at how much reinforcement is necessary to maintain the hypertensive effect.

Development of clinical program

Integrator: I gather that the Center's clinical program only came along later.

Image
John Longhurst, MD
Longhurst
:
I helped bring in the gift [from the Samueli's]. The original gift agreement didn't have any clinical components. We started in 2003 with just one acupuncturist.

Macauley
In 2008 we moved where we are now and started the clinic. We have Dr. Najm here with integrative medicine services, acupuncturists. a naturopathic doctor, massage therapist and a physical therapist. 

Longhurst:
We are designated as primary care in the system. We are much more like a private practice clinic. We have chiropractors in the community to whom we refer.

Najm:
Everyone is part-time so integration can be difficult. Several of us work at the same time. We share patients a lot. I will often bring the naturopathic doctor in with me. I'll refer to the ND when I need a nutritional approach. We meet two times each month as a group for 60-90 minutes and we'll share cases. We're working on what makes it the best team. My geriatric training helps. For many it is not as facile to be part of a team. We are planning a mind-body stress education training for providers and staff, as a team building program. I do think it is important for providers to have stress reduction.

Integrator: Are you doing outcomes research in the clinic?

Najm: We don't have collected data. We're not focused on any specific clinical issue so it woudl be particularly complicated. The research would probably be difficult.

  Pros and cons of off-site location

Integrator
Your clinic is off-campus by itself. What does that do to your options and impact?

Macauley
There are pros and cons. It's complicated. The clinic is 5 minutes, roughly 3 miles from the campus. The hospital and teaching facility are 14 miles from campus. That distance is beyond geography: the hospital is the Orange County public health hospital and sits in a lower income area. The campus and our clinic are in a higher income area. 

Longhurst: There were many constraints in the hospital. When we were there became an unofficial member of the pharmacy and therapeutics committee to try and get supplements into the clinic and failed. We split all fees with the hospital, which lowered our reimbursement.

Najm:
The location is positive in that we are not limited by hospital rules. We have more freedom. We can design an environment that is more conducive to patient interests. It also allows us to carry supplements for patients. This is really positive. The negative is that you want to be in a collaborative environment, for the regular medical staff to come to know you and have less angst. This we miss because we are removed. We are working to overcome the barriers.

Integrator:  So you have no inpatient program?

Najm: We have talked with the hospitalists, the cancer center, the end-of-life people. Our massage therapist is working with oncology and the acupuncturist was there. We are looking at what we might do with nutrition. The problem is that the hospital is bound by the [Joint Commission on Accreditation of Health Care Organizations]. If the insurer only pays a certain amount, we can't charge anything. We had to pull the acupuncturist out after trying to provide acupuncture in the cancer center. We lose money.


MacauleyBringing integrative medicine into the hospital is a huge challenge, mainly in how to pay for it.

Finances and philanthropy

Integrator
:
So what is the Center's financial model?

MacauleyDr. Longhurst has his grants. The UC system, including the campus, hospital and school of medicine, does not provide any financial support for the Center or the clinic. We're a "tub on our own bottom" as someone put it. Clinic fees, product sales, and our educational programs. The clinic requires philanthropic support.

Integrator: How much is the philanthropic contribution?

Macauley: It's about 50% of clinic income.

Integrator: Is that mainly the Samuelis?

Macauley: We have a Friends of Integrative Medicine program and various events. The Samueli's still generously support the Center.

Education programs

Integrator
: To what extent are you integrated educationally with the University and medical school?


Longhurst: We have a CME
[continuing medical education] conference every year. Every 3-4 years we have an international scientific conference. The next is in October. We bring in the best clinicians and scientists to speak. These activities have been very good for building interest among physicians. [The next International Scientific Acupuncture and Meridian Symposium is October 7-9, 2011.]

Macauley: We have a regular grand rounds. Dr. Longhurst and Dr. Najm teach some lectures to medical students.

Longhurst: Each first year medical student gets acupuncture information in physiology. Information about mind-body, hers and a few other therapies are taught. We also offer a one-month rotation for residents. They are in the lab and in the clinic, plus they take the [mind-body stress reduction] classes. We're limited in how many we can take. We've had 8 this year. At the end they write a referenced paper on a topic of their choice.

Macauley: We're had 15-20 so far.

Next steps

Integrator
: What are your new directions and next steps?


Macauley
:
We have a relatively new MBSR class that we just started in January 2011. We'd like to take it out into the community, too.

Najm: We're been focused mainly on chronic conditions. We might develop more of a niche, perhaps in autism. We're working with pediatrics. Also, because of because of my background, I am interested in a healthy aging program. We're also talking with Mary Hardy about her oncology clinic [at UCLA].

Longhurst
:
We struggle mostly with clinic funding. Since we have constrained resources, we need to make hard decisions on where to put the money. I'd like to push toward an evidence-based approach to clinic priorities.

Increasing openness

Integrator
:
What kind of reception are you getting in general?

Macauley
I wouldn't call it a seismic shift but it's very different today that it was 5 years ago. Changes are visible in the number of physicians referring and attendance at our conferences. The Chair of Anesthesiology is very supportive. He came from Yale, uses acupuncture, believes in meditation and music as useful to prepare patients for surgery. He's recruiting like-minded physicians into the department.

Najm:
I think once we are working with oncology and cardiology we can call it integration. It's a few years down the line - we've seen quite a shift in what we are allowed to do - if we give it more time we will see more pockets of integrative care.

Longhurst: I am very pleased with an undergraduate movement at UCI. There's a students for integrative medicine group that was formed. I'm a mentor for their research projects. There has been a change in attitude among undergrads, grads, med students and faculty. There is interest from the Chancellor on down, and I include the Dean in that. There is a gradual groundswell of interest. Some of the complementary modalities are beginning to take their rightful place in care.


______________________________________

Susan Samueli Center for Integrative Medicine: At a Glance

Founded
  1999
Philanthropic investment   $5.7 million ($2-million
as endowment);
research grants (3 R01s);
plus 1/2 of annual clinic
revenue is via fund-raising
Other Center revenue   Patient fees, supplements,
educational programing;
research grants (note: research
grants do not support clinic)
UC Irvine financial support   None
Areas of activity
  Research, education, clinical
services
Academic home
  Family medicine department
Research focus   Acupuncture mechanism,
cardiology applications;
3 NIH HLB R01 grants;
No clinical outcomes analysis
Educational programs
  Month-long residency; Grand
Rounds; some core curriculum;
annual CME conference;
major scientific conferences
First Clinical Services
  2003-2004
Began free-standing clinic
      
2008
Clinical location
  3 miles from med campus,
15 miles from hospital
Provider Types
    
Integrative MD, LAc,
PT, ND, Massage; also MBSR

________________________________________

Comment: The interviews with the Samueli Center's two leading medical doctors, director Longhurst and medical director Najm, struck me with the differences. They reflect a duality that shapes the integrative medicine field, for better and for worse.

Longhurst's entrance into integrative medicine was via basic research. His involvement in integrative medicine remains an unintended professional surprise. Longhurst believes that the future of integrative medicine is in
revelation of mechanism. Mechanism is the way to convince medical doctors. This is a research-focused approach that supports a medical physician-centered strategy.

Najm, on the other hand, came to integrative medicine via his geriatrics background. He grew curious about the alternatives he discovered his patients were using. He respected that some declared alternatives to be of value. He began to explore these defensively, examining potential adverse effects and drug interactions. He then grew more curious clinically. Like many other integrative medical doctors, Najm started adding knowledge and skills. These led to the broad integrative practice he offers patient today. Najm's involvement is profoundly patient-centered.

How this plays out under one roof is intriguing. Longhurst offers a short list of therapies that meet his evidence test and define his integrative medicine comfort zone. Meantime, the Samueli Center's clinic has a list called What We Treat that suggests very little could not benefit from the Center's services. Treatments are many. Therapies offered by clinician Dayna Kowata, ND, LAc, for instance, include homeopathy, Bach Flower remedies and Reiki. This is a trio that the anti-CAM bloggers love to slam.

One finds a similar duality in the Consortium of Academic Health Centers for Integrative Medicine, the 48-member organization of which the Samueli Center home, UC Irvine, is a part. Some operations and leaders are closely bound by a research-based approach. These may require more evidence of alternatives than what is typical in conventional practice, given what is known about evidence in usual care. Others are comfortable, where safety is not a concern, to mix, match and explore in the way that the consumers of alternatives and integrative practitioners outside of academia do.


In the best of worlds, this duality would manifest as a creative tension. Yet visions can collide. Best action may be slowed or paralyzed by competing orientations.

My interviews with the Samueli Center principals did not directly focus on this topic. I cannot judge the practical ramifications of this duality for the Center. Yet from early on in the interview process I found myself reflecting on ancient sayings regarding how well one can serve two masters.


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