Taylor Walsh: Health Affairs-AAMC Briefing: Integrative Health/Medicine Absent from Workforce
Written by John Weeks
Taylor Walsh on Health Affairs-AAMC & Primary Care: Licensed Integrative Disciplines Absent from Workforce Plans
Numerous whole person, integrative medicine and health professions view themselves as primary care. This ranges from acupuncture and Oriental medicine practitioners who work as general practitioners to chiropractic doctors who view themselves as "primary spine care," direct-entry midwives positioned as "primary maternity care" and naturopathic doctors who are running medical homes in Oregon, Washington and Vermont.
Integrator columnist Taylor Walsh attended the November 14 event. Walsh is a formeronline service entrepreneur and
pioneer in social media who presently consultsand
writes in the integrative health and digital media space. Based in
Washington, DC, Walsh combines two passions that are of immense
benefit to Integrator readers. He sees the importance of
transformation of our medical system and the value of integrative
practice philosophies and model in that process. His clients have included the Samueli Institute, the Institute for Integrative Health and the Casey Health Institute.Here is his report.
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A Perspective on the "Redesigning the Workforce" Briefing
and the (Non) Inclusion of Integrative health and Medicine
Taylor Walsh
Consultant, Entrepreneur and Writer on Digital Media & Integrative Health
Washington, D.C. Integrative
Health & Wellness Twitter: @taylorw
The reconfiguration of the American
healthcare workforce is a topic of intense examination, but if a national
conference in Washington last week is any indication, the role for integrative
health disciplines will remain "a hidden dimension," as described by the
Academic Consortium for Complementary and Alternative Health Care in its 2013
white paper, "Meeting the Nation's Primary Care Needs."
Taylor Walsh
Many of the nation's leaders in
workforce academic and health policy gathered in Washington Nov. 14 to discuss the
state of the workforce in light of the Affordable Care Act and the continuation
of dispiriting trends that have left the nation's healthcare professions
mismatched with the needs of many communities and patients.
The briefing was sponsored by the
magazines Health Affairsand Academic Medicine, the journal of the
American Association of Medical Colleges, both of whose current issues are
devoted to the workforce issues addressed at the briefing.
The primary take away from this
half-day session is that medical education and policy actions have been lagging
well behind and are not responding to the reality in the marketplace. Several speakers noted that this is likely to
become more pronounced as millions of previously uninsured citizens arrive to
be served by the care system. Sheldon
Retchin, MD, CEO of the Virginia Commonwealth University Health System, reporting
on VCU research on the care needs of the uninsured said the most dominant need
in this population is for mental health, which "we are unprepared for."
While the topic of non-physician
leadership in primary care and in other points of delivery was thoroughly
discussed, any role for integrative disciplines as contributors to such a
solution was oblique, at best. But it is also clear that sharing any
physician-assigned responsibility even with nurse practitioners or physician
assistants will be a tremendous culture pull that will not quickly come to
pass.
The two presenters who offered the
most potent visions for adjusting the prevailing medical education culture were
Edward Salsberg, director of the National Center for Health Workforce Analysis
at HRSA, and George Thibault, president of the Josiah Macy Jr. Foundation,
which has take a leading role in funding workforce development innovations.
Salsberg said that at HHS the
starting points for any workforce analysis and any resultant prescription is
driven by the growth of the aging population and the system's unsustainable
costs. HRSA's role, he said, was to be a
"supply stimulator;" one that reflects what he called the "disruptive
innovations" occurring in the market:
Non-physician clinician care
Retail clinics outside physician-directed or
owned premises
Attention to primary care and to prevention
New models that will affect delivery and demand:
medical homes, ACOs
Interprofessional education (IPE)
"Full use of all health workers" (the elusive
term "all" being undefined)
Teams and collaborative practices
HRSA is creating an institutional
infrastructure in an attempt to reflect these trends, such as a National Health
Services Corps and a National Center for Interprofessional Practice and
Education. He also said that workforce
planning is a "Federal-state shared responsibility."
Salsberg did not mention it, but
HRSA has already been active in "supply stimulation," by funding in 2012 the
formation of the National Coordinating Center for Integrative Medicine (NccIM,
also called IMPriME), which is now coordinating 12 HRSA
grants that support integrative education in a dozen preventive medicine
residency programs.
Thibault was unambiguous in his
remarks about the "cultural change" that is needed in medical education: "Collaborative, non-hierarchical. Delivery and education have to work
together. Listen to patients, the
community and families."
He laid out the actions needed to
bring about such a change. "First and
most important," he said, "is interprofessional education. Education processes don't reflect the team
future." "Team competencies," he said,
"become core." Other factors:
Expanding beyond the primarily hospital-based
clinical education model; develop relationships with patients and families
Integrate with even non-medical disciplines:
"bio-science is not sufficient"
Move to competency-based advancement, rather
than time-based, to reflect individual attainment
Use technology that simulates the world that
practitioners will work within: a team environment, collaboration, and
education delivered in a distributed model
Invest in faculty from diverse disciplines
Meanwhile, the imminence of the
Affordable Care Act (assuming it is not laid to rest next to HillaryCare),
brings its own considerable uncertainty, according to many of the
speakers. Atul Grover, chief public
policy officer of AAMC said, "The ACA will accelerate shortages." An audience member from the College of
American Pathologists stood to say that the likely adoption of labor saving genomic
and other technology-driven advances is causing serious concern among her
peers.
CEO Retchin of the VCU Health
System said that "the workforce won't be sufficient ... We have to look at unmet needs of the newly
insured." Michael Hoge, PhD, director
of Yale Behavioral Health and a founding member of the Annapolis Coalition on
Behavioral Health Workforce reinforced Retchin's admonition. Noting
the shortages expected for child and geriatric psychiatrists, he basically made
a plea "to broaden the concept of the workforce and enhance the skills" needed
in mental health and addiction. CODA:
It's true that the account above
constitutes a real stretch to find some linkage between the thoroughly
described problems confronting the US health care workforce - as articulated by
these policy and academic leaders -- and the vast cohort of integrative
practitioners whose presence, even though literally right around the corner,
remains to be acknowledged.
In an article in the issue of Academic Medicine published concurrently
with the briefing, George Thibault wrote that the Macy Foundation's purpose is
based on "promoting innovations in health professions education that better
align education with the needs of the public..." But what does the
phrase "needs of the public" mean today?
And what will it mean five years from how? And who determines these needs?
Perhaps "preferences" of the public
is more apt; or "expectations." Or
perhaps "...better aligning education with all the health services valued by the
public..."
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Comment: I am a co-author with Michael Goldstein, PhD of the UCLA Center for Health Policy Researchon
the ACCAHC report referenced by Walsh. It became clear to us in working with the writing groups from the chiropractic, naturopathic, AOM and direct-entry midwifery disciplines that, the exclusionary views of current planners mean they are missing a significant chunk of what, in
this patient-centered era, we chose to call primary providers of
care. Millions turn to these licensed so-called "CAM" practitioners when something is bugging them instead of their formal, system-centered primary care providers -
whether MDs, DOs, PAs or nurses. There
is no doubt that these practitioners are relieving a significant burden on the
mainstream delivery system. They should, in an open society, and more
certainly in a nominally patient-centered system one, be in the
calculations, in these journals and at the meeting Walsh reports. As Thibault noted in a workshop of the Institute of Medicine Global Forum on Innovation in Health Professional Education, we need to "widen the circle" on who is in these discussions.