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Why Isn't NCCAM's 10th Anniversary Focusing on Real World Outcomes? Answers from Director Briggs PDF Print E-mail
Written by John Weeks   
Friday, 28 August 2009

Why Isn't NCCAM's 10th Year Anniversary Symposium Focusing on Real World Outcomes? A Response from Director Josephine Briggs

Summary: When I learned that NIH NCCAM's 10th anniversary celebration in December 2009 was to focus on natural products and mind-body medicine, I was honestly deflated. Why not focus on the exciting directions toward real world outcomes and effectiveness research which NCCAM director Josephine Briggs, MD has articulated? Given the Obama administration's focus on comparative effectiveness research, this seemed a missed opportunity. Even to focus on pain conditions, another of Briggs' spoken priorities, would seem to be a more proactive direction if one's interest is in showing the value of NCCAM to the public and members of Congress. I contacted NCCAM with a series of questions. Here is Briggs' informative, thoughtful and useful response.   
Send your comments to
for inclusion in a future Integrator article.

Image
Celebrating 10 years with December 8 Symposium
The "signature event" celebrating the 10th anniversary of the NIH National Center for Complementary and Alternative Medicine (NCCAM) will be a symposium December 8, 2009. The title is "Exploring the Science of Complementary and Alternative Medicine." The focus, according to the brief note on the website, will be on:
" ... exciting areas of science, framed within the key priority areas of natural products and mind-body medicine."  
I found this displeasing, retro, even, for NCCAM. This focus would seem to continue NCCAM's initial expenditures of millions on drug trials of natural products rather than the truly exciting and challenging areas of researching the whole practice, non-reductive nature of most integrative practices into which such products are sometimes inlaid. This focus for the 10th anniversary celebration also returns attention to a body of work which has led to the conclusion among NCCAM's considerable adversaries that CAM is ineffective. Doesn't this direction feed those who would like to see NCCAM dissembled?

Finally, the focus,
set by "senior NCCAM leadership" as I was told in an August 18, 2009 email from NCCAM communications, would seem to be out of line with a direction stated in my interview last fall with the most senior of leadership, NCCAM director Josephine Briggs, MD.

My questions to Briggs and NCCAM

Image
Josephine Briggs, MD - steering the NCCAM ship
I
contacted NCCAM and Briggs with a series of questions. These asked whether this focus indicated NCCAM's future direction, especially given that NCCAM is just now engaging input on a new 5 year strategic plan; if, despite prior comments, NCCAM would be investing significantly in large herb trials again; and why CAM's potential contributions to alleviating pain conditions, about which Briggs has frequently noted a significant interest, together with their cost-savings (see recent Integrator article on the work of economist Patricia Herman, ND, MS, PhD) was not selected as a theme. Wouldn't this have been a more exciting, future-oriented direction?

Most importantly, I wondered
whether a focus in “real world outcomes” and effectiveness research for CAM, which Briggs' has indicated that she would highlight in her term as director, had been considered for this event. Given the focus on real world data in this era of necessary healthcare reform, and the Obama administration's backing of comparative effectiveness research as a tool in that effort, wouldn’t this, too, have been a more exciting direction?

Briggs responded thoroughly, and in full, via a hard-copy letter written to me August 18, 2009. Given the importance of director Brigg's thinking for the future of complementary and alternative medicine and the integrative practice field, I reprint it here, with some commentary inserted.

_____________________________

Explanatory Letter from NCCAM Director Briggs, with Comments
 

  
Department of Health and Human Services                                                  
                                                          
Image








                                                                                               
Public Health Service
National Institutes of Health

National Center for Complementary
and Alternative Medicine
31 Center Drive
Building 31, Room 2B-11
Bethesda, Maryland 20892-2182
nccam.nih.gov

August 18, 2009

Briggs: "Thank you for your recent inquiry about our Anniversary Symposium and your other thoughtful questions.

Emphasizing mechanism for NIH's basic researchers

Briggs: "First of all with regard to the Anniversary Symposium, this event commemorates NCCAM's 10th anniversary - celebrating a decade of rigorous research of more than 2,200 research projects at institutions across the country and around the world. On Tuesday, December 8, on the NIH campus, we will be hosting a day-long scientific symposium that will highlight the innovative research that is being done to understand complementary and alternative medicine. We are planning an exciting program featuring leading researchers studying natural products and mind-body medicine - from the microbiome and probiotics to pain and the placebo effect. The audience for these events is typically drawn primarily from basic scientists from the intramural NIH community, and for this event we have chosen to emphasize progress in basic mechanistic understanding. We consider this a special opportunity to showcase to an audience of scientists the achievements and fascinating scientific insights that have emerged in the past decade."
Comment: So, then, a conservative program, focusing on basic sciences and mechanism, to feed an audience which is likely populated with skeptical researchers from inside the NIH. Understandable politically as a short-yardage move, but is this direction where integrative practice has the most promise? I am reminded of Gina Kolata's fascinating June 28, 2009 New York Times article, "Grant System Leads Cancer Researchers to Play it Safe."  Kolata concludes, after examining how the grant reviewers stymie big ideas, that while "great discoveries have been made with NIH financing ... by and large it is despite, rather than because of, the review system." Logically then, to the extent that Briggs and NCCAM play to this audience, NCCAM's value to US healthcare will likely never amount to more than, well, an extract from a hill of beans.  
Real world outcomes and CER key in "going forward"

Briggs: "You ask about my thoughts on comparative effectiveness, and my interest in strengthening NCCAM'S research portfolio on 'real world outcomes.' This is a very important area of emphasis for me, going forward. It is also currently a major area of emphasis across the NIH. I am pleased to be a member of the small Comparative Effectiveness Research (CER) committee established by the NIH leadership to direct trans-NIH activities in this area. You are probably aware of the Institute of Medicine report on CER which recommended 100 national priority research topics. These topics were chosen by the IOM panel from more than 2600 topics that were considered. A number of the top 100 are of particular importance to NCCAM, including recommendations about research on acupuncture, mindfulness, dietary supplements and management of back pain. In our solicitations for the American Recovery and Reinvestment Act, we placed special emphasis on comparative effectiveness, and expect to be able to make a number of awards in this area."
Comment:  Great news to learn that Briggs has CER elevated in her thinking to the point of serving on the special NIH committee. I hope the NCCAM advisory council and staff will promote and elevate this direction. Briggs' work would be served to be informed by the thoughtful insights into CER, patient-centered care and whole practices as articulated by former NCCAM advisory council member Carlo Calabrese, ND, MPH, in his invited column, August 7, 2009, for the Integrator. Even in the CER zone, optimal research on integrative practices, as calabrese explains, has its special requirements. For more details on the place of CAM in CER and in the IOM report referenced by Briggs, check this Integrator Round-up.
Briggs: "Finally, you ask about pain research. I consider CAM approaches to pain management, particularly low back pain, to be a major priority topic for future emphasis. In all my outreach activities I am actively encouraging investigators to submit application to explore the promise of CAM and integrative approaches for pain management, including research that is the kind of 'real world effectiveness' that would fall into CER, but also basic mechanistic studies, translational tool development and efficacy studies. I certainly agree that a CAM pain symposium could be of substantial interest, but I also think we are going to see new findings over the next few years that will make such a meeting even more exciting in a few years."
Comment: Fine, let's do that meeting in a few years. But what we need in the pain/CER/"real world"/effectiveness nexus is a symposium which acknowledges that we are about changing from reactivity to disease and toward health creation, and we need research models that can help us with this direction. Briggs, her staff and her advisory council need to embrace what a complex task and Big Idea we are undertaking in shifting research toward what is truly meaningful to our consumers and health system today and tomorrow, rather than what will please the basic scientists and reviewers of yesterday. Such a symposium would be exciting not in what it is reporting out but rather in what it is developing, exploring methodologically, culturally and institutionally in this point in time when multifaceted practices that respect and are directed to the whole human are what are needed for virtually anyone with a chronic condition, regardless of whether CAM treatments are used. This is the area of NCCAM's natural leadership, if we step up.   
Briggs: "Back to the Anniversary Symposium, we will post the agenda soon on our website. I am excited to host this event which will highlight the breadth of basic research relevant to our mission. I think the symposium will showcase the rigorous science that NCCAM has funded in its first 10 years. I hope you will consider joining us."

Sincerely,

Josephine P. Briggs, MD
Director

_____________________________


Additional Comments: First, I thank Briggs for her thorough response, transparency and willingness to dialogue despite my one-note drum-beat. The dialogue here is with Briggs, but might better be also directed more forcefully toward the members of the National Advisory Council for Complementary and Alternative Medicine. This group is nominally charged with bringing energy from the community into the NIH.

   
 
Someone once said of the NIH
that it is a slow moving tanker
for which only modest changes
in direction can be made.

That will certainly be a self-
fulfilling prophecy if only modest
changes are asked of it.

 
Yes, I bet I would find the 10th Anniversary Symposium eye-opening. I do understand how people can get excited about other research questions, and how answering them can lead to major contributions. There is the excitement, for instance, of Richard Hammerschlag, PhD, and the researchers associated with the Institute for Integrative Health in exploring our understanding of "energy physiology." There is also the exploration of herbs with which I am in most contact in my work as a trustee with the American Botanical Council.

All good. All intriguing. And all, to me, somewhat academic compared to the value of best appreciating how the literally hundreds of thousands, and growing, of integrative practitioners, mostly still outside the fold, can best be used to help move our dissolute medical system toward health creation.

Someone once said of the NIH that it is a slow moving tanker for which only modest changes in direction can be made.
That will certainly be a self-fulfilling prophecy if only modest changes are asked of it.

Send your comments to
for inclusion in a future Integrator article.


Last Updated ( Friday, 28 August 2009 )
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