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A Short History in the Form of a Top 10 for the Decade in Integrative Medicine PDF Print E-mail
Written by John Weeks   

A Short History in the Form of a Top 10 for the Decade for Integrative Medicine

Summary: As 2009 ended and 2010 dawned, Top 10 lists for the 2000-2009 decade began to show up in newspapers and magazines. What a time this decade has been for integrative medicine and integrative health care! Despite having written not one but two Top 10s for the year of 2009, I couldn't resist reflecting on the decade that was. I developed this as a short history in the form of a Top 10 for a media outlet which is not inside the integrative practice field. I hope regular Integrator readers will find these reflections of interest. I look forward to any of your comments, corrections, or views about any oversights. More     
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For "integrative medicine," the movement to transform medical education and practices toward more holistic and healing oriented approaches, the 2000-2009 years marked a decade of emergence. Core institutions were established. For the related, licensed integrative practice fields such as acupuncture and Oriental medicine, chiropractic medicine, massage therapy and naturopathic medicine that are frequently lumped together as complementary and alternative medicine (CAM), the decade was similarly significant. An infrastructure for collaboration began to be developed. Influential reports were published. New policy work was ventured. All are positioned for greater influence in the coming decade.

Below is a short history of the movement in the form of a Top 10 of action and events in this past decade for "integrative health care," the more inclusive term the Institute of Medicine of the National Academies of Science favored in a 2009 report (see #9, below). The focus in this Top 10 is on collaboration, policy and integration, rather than research and science. I present these more or less chronologically. A caveat: The half of my professional life I don't spend writing I focus on organizing and guiding. I have been involved, and continue to be, in various capacities with some of the initiatives and organizations noted below. I view this less as a conflict of interest than as a testament to the still rather small community of leaders of this movement. I invite readers to come forward with any egregious oversights which my near-sightedness may have produced.

Top 10 for the Decade in Integrative Medicine and Integrative Health Care

The White House brand elevates "CAM"
1.  Publication of the Report from the White House Commission on Complementary and Alternative Medicine Policy (2001)

In 1998, during the second Clinton administration, US Senator Tom Harkin (D-IA) quietly added an amendment to a measure which created the NIH National Center for Complementary and Alternative Medicine (NCCAM). The new section created a White House Commission on Complementary and Alternative Medicine Policy to examine the policy implications of the growing consumer and health system interest in complementary and alternative medicine (CAM). The Commission's report was released in 2001 into the non-supportive atmosphere of the first Bush administration. The report has been decried as a classic governmental waste, gathering dust on shelves. Yet the imprimatur of the White House and the Commission's public process, which included hearings across the country, gave an aura of importance and sense of arrival to a movement which had been grassroots and excluded from serious policy consideration. While the report's far-ranging recommendations have only rarely served agency heads and members of Congress as roadmaps for policy changes, individual sections and recommendations ennobled the tongues and pens of scores of grant-writers and organizers who developed CAM and integrative medicine programs and organizations in hospitals, health professions schools, health systems and communities across the United States. It is fair to say that all of the development below came with some reference to the 1999-2001 work which led to the report.

Philanthropists fueled significant advances throughout the decade
Founding and Strategic Partnerships of the Bravewell Collaborative of Philanthropists for Integrative Medicine (2001)

Through the 1990s, numerous hospitals, health systems and medical schools in the United States began to establish programs in CAM, "healing health care" or what came to be known as "integrative medicine." But it wasn't until a handful of philanthropists who funded individual initiatives in hospitals and medical schools in their communities convened a national gathering of donors did this movement in conventional medicine gather steam as a significant entity. The philanthropic pedigree of the Bravewell Collaborative helped. The wealth was associated with respected names such as Bill George, former Medtronics' chair and Harvard-affiliated author on leadership, and John Mack, the recently retired head of Morgan Stanley. Their spouses, Penny George and Christy Mack, served as Bravewell's first and second presidents, consecutively. These philanthropists aimed at nothing less than transforming US health care. Their method is strategic investment and partnership, working with many of the nation's medical schools, public television, the Prince's Foundation in England, the Institute of Medicine (IOM). Most recently, they announced a major initiative with the IOM and the 40-million member AARP to create a Healthy Nation Partnership which expands the Bravewell focus from integrative medicine to advancing general health and wellness. Bravewell's handiwork is work is evident in others of these Top 10 initiatives throughout the decade.

Consortium grew to 44 academic medical centers
.  Founding and Expansion of the Consortium of Academic Health Centers for Integrative Medicine (2002) 

After a series of organizing meetings beginning in July 1999, a group of 11 North American medical schools with integrative medicine programs formally incorporated the Consortium of Academic Health Centers for Integrative Medicine (CAHCIM) in 2002. Member institutions now total 44 North American medical schools, each of which have formal backing by their Dean of Medicine. CAHCIM members began by defining their field and then created a resource of potential course content to re-shape medical education.  In the medical education bible, Academic Medicine, CAHCIM published a consensus paper on competencies for the practice of integrative medicine, and later organized a 50-page special section in which many of their integration initiatives were featured.  One CAHCIM member, the Arizona Center for Integrative Medicine, founded by Andrew Weil, MD and directed by Victoria Maizes, MD, MPH, created a Fellowship in Integrative Medicine that has become a standard for academic in the field. CAHCIM mounted two successful research conferences. The most recent, in 2009, drew over 800 researchers, from diverse disciplines and 23 countries. With members from respected private institutions (Harvard, Stanford, Yale, Duke, for example) and major public academic centers (such as Michigan, Washington, Oregon, Wisconsin, UCLA, UCSF and Massachusetts), CAHCIM has established an undeniable foothold in academic medicine. Notably, the organization began with seven-figure backing from the Bravewell and Bravewell's leading philanthropic partners. Dues payments came later. CAHCIM is here to stay.

Advocacy group has record of accomplishment amidst chronic underfunding
The Founding and Action of the Integrated Healthcare Policy Consortium (2003)

Starting in 2000, individuals who viewed this new movement as one which necessarily required a broad coalition of stakeholders if significant transformational action in U.S. medicine was to be successful began to convene a series of meetings. Typically included were professionals from the licensed CAM disciplines, integrative, holistic and functional medicine physicians, academic leaders, plus representatives from those hospitals, payers and government agencies with a known interest in fostering integrative practices.  Three Integrative Medicine Industry Leadership Summits were convened from 2000-2002. Georgetown University hosted a National Policy Dialogue to Advance Integrated Health Care in 2001. These led to the formation of a 501c4 lobbying organization called the Integrated Healthcare Policy Consortium (IHPC). Despite a history of minimal funding, IHPC left a considerable legacy through the decade: placed a licensed acupuncturists and a naturopathic physician on the AMA's influential Current Procedural Technology (CPT) coding committee; mounted the National Education Dialogue to Advance Integrated Health Care involving educators from 12 disciplines; created the Academic Consortium for Complementary and Alternative Health Care (ACCAHC - see #7); and had a leading role in lobbying language in US Senate health reform legislation in 2009 to create more inclusion of licensed CAM and integrative practitioners and wellness initiatives. Despite its record, however, IHPC continues to struggle to support itself.

The nation's most ambitious pilot for integrative practices
Health Systems Integration Initiatives at Allina (2004) and the Veterans Administration (2001)

The integration of US medical delivery with new integrative healthcare and wellness-oriented approaches requires ambitious pilots to model the way forward. Two initiatives with vastly different origins merit mention. One is the Congressional requirement, lobbied by the chiropractic profession and currently directed by Anthony Lisi, DC through which chiropractors are being placed onto the staff of hospitals and clinics throughout the Veterans Administration system. Both the VA and the chiropractic profession are learning a good deal about intimate co-habitation and the competencies on each of their parts for working together. The mandated experiment is slowly expanding. In fact, some VA hospitals are also now working with institutional partners to bring in licensed acupuncturists.  Meantime, in the private not-for-profit sector, Minnesota's Allina Hospitals and Clinics has committed to an integrative health care model throughout their 11 hospital system. Integration began in earnest in 2004 at Allina's Abbott Northwestern Hospital. Over 60,000 integrative visits to patients have been provided under the overall clinical direction of holistic nurse Lori Knutson, RN, HN-BC.  Most are massage, acupuncture and energy healing methods. Backer Penny George, the founding president of the Bravewell (see #2), views the Allina initiative, as a pilot to support broader adoption of the integrative model in healthcare reform. To fulfill on that vision, the Allina team will need significant research dollars to measure and report these real world outcomes. (See #8, below.)

Institute's initiatives spun numerous threads of influence
Wayne Jonas, MD, the Influential Samueli Institute (2001) and its Wellness Initiative for the Nation (2008)

As director of the NIH Office of Alternative Medicine in its formative years in the mid-1990s, Wayne Jonas, MD promoted a view of research which included both basic research questions (mechanisms by which acupuncture and mind-body therapies work, for instance) and pragmatic approaches that sought to measure outcomes of the CAM practitioners and therapies already widely in use by the consuming public. Jonas' views sometimes put him at odds with more conservative NIH officials. After he left the OAM, Jonas encountered Susan Samueli, a CAM user and advocate. The two, with the support of the wealth from the $4-billion Broadcom firm that her spouse Henry Samueli co-founded, created a parallel research institute. One division of the Samueli Institute partnered with the American Hospital Association to advance understanding of CAM integration and optimal healing environments in the nation's hospitals. Another partnered with divisions of the US military to examine diverse CAM interventions which might assist the military, from yoga and mindfulness to acupuncture and nutritional supplementation. A third included a partnership with Georgetown University scientists to explore basic relationships between the brain and healing. In a significant public policy effort begun in 2008, Jonas kicked off a Samueli-led campaign called the Wellness Initiative for the Nation (WIN). Through WIN, Jonas and the Samueli Institute educated members of Congress about the need for a whole system agenda to help create a wellness focus in not just U.S. medicine but throughout federal agencies that contribute to health and wellbeing. As of this writing, some of these ideas have a foothold in a section of the US Senate-passed reform legislation that would establish a National Prevention, Health Promotion and Public Health Council. The Samueli generosity, through Jonas and his team, has created numerous threads of change throughout the healthcare system.  

15 organizations from 7 disciplines commit to membership and collaboration
Founding and Development of the Academic Consortium for Complementary and Alternative Health Care (2008)

Collaboration, inter-professional education (IPE) and teamwork are hallmarks of good clinical care, particularly in the new era of chronic disease. Consumer use of CAM and the licensed CAM professions has fostered new questions relative to collaboration and the integration of these services with conventional treatment. Recognizing these challenges, most of the councils of colleges, U.S. Department of Education-recognized accrediting agencies and certifying and testing organizations linked to the five licensed CAM professions began working together in 2004 as the Academic Consortium for Complementary and Alternative Health Care (ACCAHC). The organization, incorporated in 2008, currently has 15 national organizations (including 3 from the emerging fields of yoga and Ayurvedic medicine) working to elevate the ability of educators and practitioners to collaboration. They have published a reference text on their disciplines, completed and presented research to help their educators on competencies of CAM practitioners for working in integrated settings, contributed to research meetings and engaged dialogue with academic colleagues in CAHCIM (see #3, above). They developed consensus on shared research priorities of their disciplines and presented these to the NIH National Center for Complementary and Alternative Medicine (see #8) and successfully advocated for a role in the planning committee for the IOM Summit (see #9). The latter ensuring that the licensed CAM disciplines would have at least a single representative in the process. (Note that this, #7, is where the reader must be most beware of bias: I helped co-found ACCAHC and currently serve in a part-time capacity as the organization's director.)

Stakeholders urge course shift in next strategic plan
Multi-organizational Advocacy of a "Real World" Agenda for the NIH National Center for Complementary and Alternative Medicine (2009)

When members of Congress created the NIH National Center for Complementary and Alternative Medicine (NCCAM) in 1998, they mandated that the top priorities for research investment would be the real world areas of effectiveness, outcomes, cost, and how to integrate CAM therapies and practitioners with the conventional delivery system. They argued that consumers, hospitals and even insurers were already involved with these licensed CAM practitioners and their therapies so let's focus on what that use means. Instead, NCCAM's first director, the now-deceased Stephen Straus, MD, pushed the roughly $120-million a year of funds appropriated to NCCAM toward a more standard NIH agenda of basic research and randomized controlled trials. General consensus is that little new information was produced to help understand the value to consumers and health system stakeholders that may come from integrating these therapies and practitioners with conventional medicine. Current director Josephine Briggs, MD, while sharing with Straus a lack of background in any integrative practice field, has shown herself an avid listener. NCCAM stakeholders including holistic medical doctors, naturopathic physicians, yoga therapists, CAM educators and massage therapists have urged Briggs toward a real world, effectiveness agenda for NCCAM's 2011-2015 strategic plan that is now in development. These practitioners want research that examines not single agents but rather the whole systems, multi-modality, mind and body approaches they typically use with patients. This is the first of NCCAM's three 5-year plans in which so many professional stakeholder organizations has responded. Briggs has shown some alignment with this direction in some public statements, media interviews, and through taking a lead role in the NIH's comparative effectiveness research committee. An affirmative decision to align NCCAM's spending with this direction could begin to give us quality evidence of the value of integrative medicine and integrative practices in our health systems - for instance those mentioned in #5, above.

The largest and most diverse meeting in IOM history
Institute of Medicine National Summit on Integrative Medicine and the Health of the Public (2009)

The Bravewell Collaborative (see #2) got the ball rolling in early 2008. They created a partnership with the Institute of Medicine of the National Academies to mount the National Summit on Integrative Medicine and the Health of the Public, held February 25-27, 2009. The IOM was not new to the field. In 2005, the quasi-governmental agency had published a volume on the use of complementary and alternative medicine. Bravewell chipped in $445,000 of sponsorship funds. By design, top integrative medical thinkers and scientists were linked with conventional medical leaders and business executives in the planning and execution of the Summit. Ralph Snyderman, MD, a Duke University Medical School Emeritus Dean chaired the team. Multi-professional teams that included medical doctors, nurses, naturopathic physicians, chiropractor s and licensed acupuncturists produced a series of working papers. The overflow gathering of 600 was celebrated in a November 2009 report as the largest and most diverse meeting in the history of the IOM.  While conventional medical doctors, academics and healthcare industry leaders dominated, significant subsets of representatives from the licensed CAM fields and emerging fields such as Yoga therapy participated. One recurring theme, supported by the IOM authors of the report, was that "integrative health" or "integrative health care" may be better and more inclusive phrases for describing the movement that the Summit has capturing than the more MD-centric "integrative medicine." While a report of a meeting rather than a series of recommendations, the IOM's text clearly has a feel of advocacy for the ascendance of integrative practice and associated health-focused principles as we deal with more fundamental health reform questions.

Slowly, a presence in the Beltway
Beginning to Show Up: Integrative Practice Interests and Federal Healthcare Reform (2009)

US Senator Tom Harkin told attendees of the IOM Summit (#9) that he wanted to "place integrative health care at the heart of the 2009 health reform debate." It didn't happen for the same reason that CAM and integrative care have not advanced significantly since the report of the White House Commission set a roadmap for CAM policy work in 2001. Namely: of integrative practice interests, all but chiropractic have had virtually no presence in Washington, D.C. In 2009, some positive trends become visible. The American Association for Acupuncture and Oriental Medicine mounted its first profession-wide lobbying effort, promoting inclusion in Medicare and Federal Employee Benefits Plans. The American Association of Naturopathic Physicians gained inclusion in language relative to Indian Health Services. A consortium of midwifery organizations raised some $200,000 to support a campaign for homebirth services in Medicaid, gaining a foothold for the services of Certified Professional Midwives in birth centers. The IHPC, as noted above, helped place language inclusive of licensed CAM and integrative practitioners in the Senate version of the reform bill. The Samueli Institute, working with the IHPC and others, made headway in promoting a whole system view of creating a "wellness society," as Senator Harkin calls it. Meantime, high-profile integrative medicine leaders like Dean Ornish, MD, Mehmet Oz, MD and Mark Hyman, MD testified before Congress and worked their personal networks on behalf of whole person, wellness and functional medicine approaches. The financial support for these efforts remained but a homeopathic dose compared to the millions spent on lobbing by stakeholders that are the foundation and pillars of the medical-industrial complex. Only chiropractic was making the kind of significant campaign contributions needed to put anything at the heart of a debate.

The good news at the end of the decade is that the integrative medicine and integrative healthcare communities are beginning to have the infrastructure, organization and wherewithal to show up and be heard. Chances to do so will be coming. From all signs this morning after the special election in Massachusetts, further rounds of health reform remain ahead of us.

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