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Your Comments Forum: 8 Voices on Integrator Themes PDF Print E-mail
Written by John Weeks   
Sunday, 26 October 2008

Your Comments Forum: 8 Voices on Integrator Themes

Summary: Dan Redwood, DC on my assertion that chiropractic is historically Republican leaning ... International Association of Yoga Therapists leader John Kepner on two guiding lights for his work from the White House Commission ... Historian and holistic nurse Martha Libster, PhD, RN, CNS on lessons from the mid-1800s ... ND student Naini Kohli urges a patient focus in the dialogue over who owns integrative medicine ... AsOne Coaching Institute founder Linda Bark, RN shares data from Aussie study showing huge return for employers ... Michael Levin wonders whether new data on the conscious use of placebos by internists and rheumatologists suggests openness to the mind-body connection ... Herbalist and hospital integrative medicine leader Sara Eisenberg, MS challenges my perspective on the column by Bhaswati Bhattacharya, MD  ...  Georgetown law professor and long-time AOM leader Sherman Cohn, JD argues that patient care has been changed by the integrative practice movement ...  Glenn Hoey, ND comments on business realities of a naturopathic practice.
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Daniel Redwood, DC
1.   Dan Redwood, DC: On whether chiropractic is "historically Republican leaning ..."


Dan Redwood, DC, is an associate professor at Cleveland Chiropractic College. He wrote in response to the Integrator article on Obama and McCain's views of chiropractic and integrative practice.
I have been around chiropractic politics for long enough to know that it is an oversimplification to call the American Chiropractic Association (ACA), or the chiropractic profession, “historically Republican-leaning.”

The ACA, the International Chiropractors Association and chiropractic state associations (I have served as a state legislative chair) are pragmatic and work with the hand they’re dealt. When there is a Republican majority in a particular legislative chamber, the associations do what is necessary to exert influence through Republican channels. When the Democrats are in charge, they do what they must to exert influence through Democratic channels. PAC donations are generally well divided between the parties, so that we don’t have all our arrows in one quiver.

While these organizations endorse congressional and senate candidates from both parties who have shown their support for chiropractic issues, I do not recall a presidential endorsement during my career.

The ACA has not endorsed Obama, but it is quite striking that he was the only 2008 candidate in either party to actually answer ACA’s questionnaire. His answers were specific and quite supportive. He has also sent two additional letters of support, including the recent one you highlighted.

Despite repeated overtures from Republican chiropractors and the ACA, McCain has never replied to the ACA questionnaire and has never sent a letter of support. He is the first presidential candidate in my memory to fail to even offer a general letter of friendship and support.

Daniel Redwood, DC
Associate Professor, Cleveland Chiropractic College
Overland Park, Kansas
Editor-in-Chief, Health Insights Today

Comment: The evidence for my statement that linked chiropractic with Republican views historically is from two sources. One is through personal encounters with a number of leaders of the chiropractic profession in recent years. The other is the general don't-tread-on-me, Libertarian and anti-government bias of many alternative medicine leaders 30 years ago which grew, in part, out of experiencing various federal agencies as agents of suppression or harassment. Redwood's perspective is good.  I'll put a query out to the ACA to see if they have any specific survey data. Meantime, here is interesting analysis of where chiropractic dollars have gone in recent years, roughly split, but favoring Republicans - and also supporting Redwood's view.


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John Kepner, MBA
2.   IAYT's Kepner on the White House Commission: ".. galvanized me to action..."


John Kepner, MBA is having a significant impact on the evolution of Yoga therapy in the United States, and abroad, through a series of strategic directions he has helped set for the International Association of Yoga Therapists (IAYT). Kepner read the recent interview with James Gordon, MD, past chair of the White House Commission on CAM Policy and responded with the following.
I especially enjoyed the interview with Gordon. I read the White House report and wrote one of my first articles for Yoga about that report.  Indeed, that report galvanized me to get more involved with IAYT.  Two things in particular stood out.

  • ]Yoga therapy] needed a comprehensive professional association in order to effectively participate in public policy efforts like that, and

  • The professional organizations in the same field need to work together when communicating externally.  For example, one of the commission members told me that 4 different chiropractic organization told the commission 4 different things, so they threw up their hands.  They could not easily sort out differences within the same field.

So, that one example also spurred me to work hard at working with the other Yoga organizations, especially when communicating externally to our field.

John Kepner, MBA, Executive Director
International Association of Yoga Therapists

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Martha Lipster, PhD, RN, CNS
3.    Martha Libster, PhD, RN, CNS:  Mid-19th history speaks to present healthcare integration issues


Martha Libster, PhD, RN, CNS is a
a holistic nursing leader who heads up ethics work for the American Holistic Nurses Association. She is also a professor of nursing at East Carolina University. She wrote in response to the brief journey's into our history in the column by Marty Rossman, MD about mind-body influences and my column which explored common origins between the distinct disciplines in the integrative practice movement.
Have you ever discussed the history of mid-19th century American healthcare reform with your readers? That period is one of my areas of research and scholarship. It was a time when Americans actively pursued healthcare freedom as the foundation for all other freedoms. And much of what we have written about as integrative care  today is founded in what I refer to as the cultural diplomacy of the past.

So much of the history really speaks to many of the present issues. Given that history does in fact repeat itself, some might be interested ...

I also have a new book coming out in February called Enlightened Charity that is a mid-19th century history about the entrepreneurial reform work of the Daughters of Charity nurses in psychiatric care, that was holistic and considered "enlightened" by the public, nurses, physicians and health reformers of the period. Much gratitude for your fine work

Martha M. Libster, PhD, RN, CNS
Associate Professor of Nursing
East Carolina University

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Naini Kohli, ND student
4.  ND student Naini Kohli: "Time to stop finding faults with each other"

Naini Kohli is a medical doctor from India who is close to completing a naturopathic medical degree at the University of Bridgeport College of Naturopathic Medicine. Kohli wrote that she "gave up a reasonable medical practice of over 10 years for the cause of integrative medicine." Her comment regards the sometimes heated Integrator dialogue on who owns "integrative medicine."
I think integrative medicine is the meeting point of allopathic and naturopathic medicines combining the best in each one of them. Both have a lot to complement each other. It is high time we stopped finding faults in each other and come forward with an approach which serves the common goal of all healthcare practitioners: a healthy patient with a healthy mind and a healthy body.
Naini Kohli, Naturopathic Medical Student (MD-India)
University of Bridgeport College of Naturopathic Medicine

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Linda Bark, RN
5.    Linda Bark, RN:  Health coaching saves $3 for every $1 in Aussie study


Linda Bark, RN and I began a little dialogue about the potential role of health coaches following a column on the work of the Institute for Health and Productivity Management on employer exploration of complementary and alternative approaches. Bark, the founder of AsOne Coaching Institute, suggested that health coaching would potentially be very valuable agents in advancing health and productivity of employees. Bark recently sent me this note, and link.
This info on coaching is from a blog associated with The Daily Telegraph in Australia:
"A pioneering NSW health fund, Australian Health Management, has found that the best way to get us to change our behaviour is to give us a personal coach. For every $1 it spent on paying for this coaching for its members, it saved $3 on medical and hospital bills.

"In many cases this personal coaching wasn't aimed at making fund members lose weight, but at stopping them putting on any more weight and keeping them fit. "
Linda Bark, RN
AsOne Coaching Institute

Comment:  The idea of assisting individuals toward change is built into a lot of integrative practice. My perception is that such coaching tends to decline the more the practitioner enters the third-party payment system. Meantime, many large employers are contracting with coaching firms to allow telephonic coaching for identified subsets of their employees. Others are using virtual systems where coaching is through interactive programs. If integrative practices are to be agents of change in moving our system toward a focus on health and wellness, clarity on strategies for supporting such behavior changes will be critical, whatever the type(s) of practitioners that might be used.  


5.   Michael Levin: "Are half of US internists and Rheumatologists practicing mind-body medicine?"

Integrator
columnist Michael levin sent me this short reference on palcebo, with a provocative question about how deeply mind-body practices are already embedded in conventional practices through the conscious use of the placebo.
Interesting story on NPR: Survey: U.S. Doctors Regularly Prescribe Placebos.

The head of Ethics at NIH published a study in the British Medical Journal. A survey of 700 US internists and rheumatologists showed that half of them regularly (ie, 2-3 times/month) prescribe placebos to patients w/o the patient's knowledge.

Ezekiel Emanuel, MD, the NIH ethics chief, states. "I think we're all just a little nervous about that as a common practice," he says. "Even though it might be on the right side of deception, we're not being fully frank with the patient."

But Emanuel doesn't condemn all placebo use. After all, he says, it shows that American doctors understand that the mind plays a big role in healing, and that's not a bad thing.

Is this another way of saying that half of US internists and rheumatologists practice mind-body medicine?

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Sara Eisenberg, MS
6.    Sara Eisenberg, MS
: "disappointed with comments" on Bhattacharya

Sara Eisenberg, MS has more than 30 years’ experience as a healing arts guide, facilitator, leader and major hospital-based integrative medicine leader and educator. Eisenberg took issue with my comments in the article entitled
Bhaswati Bhattacharya, MD: Lessons from an Ayurvedic Experience of Sustainable Integration (August 22, 2008). Eisenberg holds a Masters of Science degree in Herbal Medicine and is currently is in practice as an herbalist and healer at Ruscombe Community Health Center in Baltimore. She has authored an ethnobotanical monograph on Ashwagandha, a rejuvenatory plant in Ayurvedic medicine.
I was disappointed to read your uncharacteristically flippant book-ending of Dr. Bhattacharya’s submission on the elements of a sustainable integrative practice ("Anyone for softening all consultants through submergence in healing oil?") It seemed to me her thoughts are especially relevant in light of your recent referencing of the frequent exclusion of CAM clinicians from policy-setting and educational texts/bodies, and your questioning as to whether integrative medicine "belongs" to board-certified physicians in the US.

   
  Eisenberg:

It is not just the exclusion
of clinical relevance that
fails to serve inquiry, but
the exclusion of different,
coherent, and millennially
time-tested systems of
medicine such as Ayurveda,
Chinese and Tibetan medicine,
and indigenous tribal practices.
 

It is not just the exclusion of clinical relevance that fails to serve inquiry, but the exclusion of different, coherent, and millennially time-tested systems of medicine such as Ayurveda, Chinese and Tibetan medicine, and indigenous tribal practices. There is much to be gained by understanding the world-views of such systems, not the least of which is to recognize the true value – and real limitations of, the double-blinded, placebo-controlled randomized controlled trial, and the distorting economic influences surrounding the funding of research and the "recouping" of investments through patentable drugs.

In the scriptural texts of Ayurveda the literal meaning of health (svasthya) is to be established in oneself. Health depends on the cultivation of habits which sustain proper order within a person. Such a healthy routine (din charya) prescribes daily time frames for various activities, according to the seasons and to the individual’s constitution. Temperature extremes and environmental toxicities are recognized as external causes of disease. The primary internal perversity of mind, or volitional transgressions or crimes against wisdom. Place Dr. Bhattacharya’s list in this context, and you can begin to see the deep wisdom of what might otherwise appear to a reductionist western mind as "exotic" or "eccentric." Might these concepts be of use to us in addressing major current public health problems?

As a clinical herbalist, clients that I see are overwhelmingly challenged by what I think of as dysfunctional rhythms: irregular patterns of meals, activity and rest, and a failure to make seasonal changes in such patterns. These irregular rhythms, driven by varying mixes of psychological, social, and financial needs, show up as common physiological dysfunctions: interrupted sleep, female cycle irregularities, and disrupted patterns of breathing, digestion, and metabolism among others.

I am greatly aided in assessing these clients by medical diagnoses, laboratory findings, physician contact, and evidence-based plant research. With these alone, I am of little use to my clients, who long to be seen and known as the full dimensional beings they are – thoughtful and feeling, brave and scared, creatures of habit and working at self-responsibility, social and creative and imperfect humans. One key ally is observational skills- not just mine as practitioner, but my effectiveness in educating my clients to observe, record, and remember what results from specific choices; understanding how patterns emerge from the aggregation of dozens of choices made daily. With a complete, dimensional assessment, and this essential client feedback, I am in a good position to design herbal formulations to "gentle" the body and psyche to move further and further along towards healthy function.

   
Eisenberg:

In one moment of particular
candor, a national [hospital]
staffer cut to the chase, in
all seriousness opining that
successful CAM operations
could endanger the financial
well-being of member hospitals
by significantly reducing
disease populations in need
of their services!

 
As Director of a CAM center at a community hospital for six years (‘97-’03) I participated on a national Advisory Council (where you and I briefly met) for a national healthcare system which at the time operated more than 30 hospitals across the country. For over a year we engaged in lively exploration of the contributions that CAM could make if integrated into such a system, and the many practical challenges to designing and executing any such plan. In one moment of particular candor, a national staffer cut to the chase, in all seriousness opining that successful CAM operations could endanger the financial well-being of member hospitals by significantly reducing disease populations in need of their services! Not surprisingly, over time the system’s interest in and commitment to CAM dwindled.

In the second century BCE Vagbhata, physician and author of the Ashtang Samgraha, urged his colleagues to pursue "the best knowledge," which was to be gained by participating in a "scientific conference"  (tadvidyasambhasha parishad). So, consider drawing a different set of conclusions from Dr. Bhattacharya’s list: the "best knowledge" will most likely emerge from wisdom exchanged openly among "conventional" and traditional medicine clinicians.

Sara Eisenberg MS

Clinical Herbalist
Baltimore, Maryland
Comment:  When I responded to Bhattacharya, I was honestly imagining how good it would be if every hospital consultant, including some who must have been in the room with Eisenberg in that process from ’97-’03, had been first “bathed in oil,” literally, and figuratively - as in fully immersed in quality integrative thinking. I think the outcome would be good. Apparently, I could have used a good dosing myself. What may have come off as flippant was likely been due to my own ignorance and cultural uncertainty. Bhattacharya does make a lot of claims in the column.  I don’t tend to accept such claims from those whose culture I better understand. Why should I accept them from a place that, to me, is in fact exotic, not having been there, nor having studied the field?
 


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Sherman Cohn, JD
7.   Professor Sherman Cohn, JD: Signs of positive changes


Sherman Cohn, JD, a professor of law at Georgetown University Law Center and a long-time leader in integrative care, reminds me from time to time that half-empty is not the only way to view the glass. His guest column last year provided a useful perspective on the advances in the field. (See
Georgetown Law Professor Sherman Cohn on How Far We Have Come in Integrating Care, October 26, 2007.) He subsequently sent me a similar update, which I re-encountered recently and thought valuable to publish. Enjoy this evidence of advancement.
The Law school seminar [on complementary and alternative medicine which I teach] has 24 students this year.  Too many, but I found it hard to say no to those who are interested.  When we started this seminar seven years ago, we had three students.

The MS in CAM offered at the Georgetown Medical Center has reached its capacity of 30 students. They had over 100 applicants this year. When they started the MS program five years ago, there were eight.

I learned yesterday that the Medical Center offers to freshmen medical students an elective Mind-Body Medicine course limited to ten students each.  There are now nine sections of the course, constituting about 50 percent of the freshman medical school class.  Next semester, we will offer such a course (non-credit) at the Law Center.  The Mind-Body Medicine course is modeled after what [James Gordon, MD] has developed. What does all of this say?
When Cohn sent me this, I wrote back stating that, to me, the interesting question in all of this action is: Do you believe that the average patient care has changed? When will we know that it has?  Cohn then replied:
Over the weekend, I read the articles in Academic Medicine on the Insights from Education Initiatives in CAM, by the medical schools that received the 15 R-25 grants. (Vol. 82, No. 10,. pp. 919-961.) Much happened at those medical schools.  Some is bound to rub off. 

   
   Cohn:

Perhaps I am an optimist.  
But could you have imagined
this happening ten years ago? 
I could not.

The most interesting, perhaps, is the article "Using Complementary and Alternative Modicine Curricular Elements to Foster Medical student Self-Awareness" (pp. 951-55).  I cannot imagine those students not being impacted as they become physicians and I rather expect that the impact will continue In those schools from class to class. Perhaps I am an optimist.   But could you have imagined this happening ten years ago?  I could not.

No, I do not think so.  At least not yet.  But to me there appear to be openings for change.  Very little happens in life suddenly.  But evolution does occur.  I have an acupuncturist friend who was hired several years ago at Jefferson Hospital in Philadelphia.  He found himself ignored by the MDs. So, he started offering free services to nurses and staff. They liked it and found "improvement," whatever that meant to each of them.  Soon MDs started coming for their personal issues. Then an MD asked him to "consult" on a patient where the MD was having difficulty. Something worked. So another "consultation" occurred.  Then another and another.  Before long, he was very busy working side by side with MDs.  So much so that another acupuncturist was hired, and this time welcomed full force.  Change occurred, slowly -- and it continues to do so.  Perhaps not as you, or I, would want it to -- but naturally and organically.  

   
Cohn:

Change occurred, slowly --
and it continues to do so. 
Perhaps not as you, or I,
would want it to -- but
naturally and organically.
  
 
Have you watched the "wellness" evolution occurring before our eyes?  Georgetown University, as an employer, is now pushing wellness. Last week the President of the University led a walking exposition. And the Dean of the Law Center led a jogging group for those who jog and walkers for those who do not.  Signs are up about walking down, and up, stairs instead of using elevators. The cafeteria has "healthy" food and promotes it. Vegetarian. Whole grains.  Wellness consultants are everywhere. Blood pressure may be measured, and weight-loss consultants are present.  Massage therapy is available on campus for students, staff, faculty.  A new fitness center opened for the Law Center with a staff that promotes yoga, massage, and meditation.   Acupuncture demonstrations occur.  Students are advised on how to start wellness habits now, including meditation, so that they can continue being well as they go into their professions.

And I am confident that Georgetown is not the only employer who is doing this.  Have you hard the Kaiser Permanente radio adds promoting wellness?

   
  Cohn:

I am confident that Georgetown
is not the only employer who
[is pursuing wellness].  Have you
hard the Kaiser Permanente radio
ads promoting wellness?


About five years ago, my internist starting probing about diet.  And advocating Vitamin C and E and Folic Acid.  Last week, as I went through a physical, he said that he was going to test my Vitamin D -- necessary, he said, to absorption of calcium. None of this occurred in the past.  He knows my interests and, when I hear these things, I kid him about catching up on what many of us have been doing for years -- asking if his medical literature has changed for the better.

So, has "average patient care changed"?   I think the answer is Yes -- not as much, not as fast, not as radically as you and I would like.  But change is occurring, slowly, organically, but occurring.  And I think for the better.

You, of course, may view the glass as half empty.  It is your right --

Sherman L. Cohn, Professor of Law
Georgetown University Law Center
600 New Jersey Avenue, N.W.
Washington, D.C. 20001-2075
 
8.   Glenn Hoey, ND:  Business challenges for graduating NDs

Glen Hoey, ND was a member of one of the first graduating classes of Johnm Bastyr College of Naturopathic Medicine (now Bastyr University), in the early 1980s. He quickly set up a practice in Wenatchee, Washington, in hte apply country eat of the Cascade mountains, where he has been since. While web-surfing, Hoey encountered the Integrator dialogue on the salary survey of naturopathic practices carried out by the American Association of Naturopathic Physicians. (See Your Comments: Income Influences for Naturopathic Physicians, January 26, 2007.) His reading provoked these thoughtful views.
I found your article on the net.  Very well written and accurate.  I was one of the no-respondees for the reasons discussed.  Personal decisions to remain in a less lucrative market rather than move my family.  I didn't feel like sharing my less than phenomenal success story.  I am sure there are many others who feel the same.  We love what we do (when we are doing it) but know it is not an equal playing field.  If one does not have an aggressive, salesman personality, it can be harder to build a practice. (How many MD's would have great practices if it were a different system?)  I think what will ultimately help will be equal access through the state and federal insurance programs, Medicare, Medicaid, etc.  That may give us more opportunity to be hired in conventional practice settings.

Glenn R. Hoey, ND
Wenatchee, Washington
Comment: Hoey's point about the need of non-conventional practitioners to be both clinicians and rah-rah calespeople for their own practices point out one of the major areas of cultural misunderstanding between conventional practitioners and those from the less-recognized and included fields. Clinical proficiency alone can be a quick route to bankruptcy. I asked Hoey to be remind me of where he is based in his practice.
I am in Wenatchee, WA.  I was referring to the article written about the survey of Naturopathic physician incomes done a few years ago.  I am not surprised at the low return rate.  Those who responded  were either established docs with reasonably decent practices or new docs that were getting started.  I would bet that many others who did not respond were perhaps embarassed to share their numbers.  My concern is that as the cost of Naturopathic education continues to increase, it will dramatically climb past the return on investment.  It would be interesting to compare incomes of doctoral level professionals to see where an ND income falls.  My guess is that it would be somewhat low.

The challenge for an ND is that it typically takes several years to grow and establish a decent practice.  There are many factors involved in building a practice, many of which are beyond the control of the doctor.

My wife finished her Nurse Practitioner program a few years ago and had an immediate practice in a community health clinic.  No radio, No TV. No flyers.  No handing out tons of business cards.  No having to join Rotary or referral clubs.  Many of her patients would benefit from Naturopathic care.  The bottom line is that I would see a very few of those patients. It is all about access.

Glenn R Hoey, ND
Wenatchee, Washington
Then, following a further note from me, Hoey wrote back:
It just seems sensible that the Naturopathic colleges would have a lot at stake in the development of the profession.  If there are a significant amount of student loan failures then the college is at risk for losing the funding.  If the only job hope is private practice, requiring more debt to set up an office, then it comes off as a $100,000 + roll of the dice.  Factors such as location, demographics, and personality traits are all important in the success of a small business.  These subjects are typically not taught in school.  I know that for me, I looked at 5-year blocks of time to assess the relative growth in my practice.  5 years! I live in a small conservative community in eastern Washington.  I compared my numbers to colleagues in Bellingham, Seattle and Olympia and I wasn't even close to theirs.  I thought it was me.  I must not be a good ND because my numbers were lower.  I don't think I am the only ND who ever thought that way, either.  That it why I believe that we need to expand the job potential to other markets.  Otherwise, the profession may eventually stall, for purely economic reasons.

Glenn R. Hoey, ND
Wenatchee, Washington


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