NCCAM Director
Josephine Briggs

In the last couple of years, NCCAM has gradually developed its web site to be more responsive to public interest in CAM and integrative medicine. In May it took another step and launched a blog written by director Josephine Briggs, MD. Readers may make comments on each post, which are reviewed before being added.

In her post of May 24, “Integrative”—What Is in a Word?
Briggs focuses on a topic of signal importance as the field begins to become far more integrated with and understood by convention practice and therapy: the definition of “integrative medicine.”

This “integrative” trend among providers and health care systems is growing. Driving factors include perceived benefit in health or well-being, emerging evidence in at least some cases that perceived benefits of integrative are real and/or meaningful (e.g., management of chronic pain), and marketing of “integrative care” by health care providers to consumers.

In her post of June 18, 2012, Dr. Briggs reports from the recent NIH Pain Consortium’s 7th Annual Symposium on Advances in Pain Research.

Briggs reports that she “…enjoyed hearing about rigorous studies testing nonpharmacological approaches, such as massage, behavioral therapies, and mindfulness meditation.”

Clearly, drugs are, and will remain, critically important in managing pain, but drugs alone are not enough. There is another important piece to pain management—patients also need strategies for self-care and ways to harness the huge impact that context, attention, emotional state, and reassurance can have on pain. NCCAM is bringing a special contribution to pain research by pursuing promising, nonpharmacological approaches to pain management; about 30 percent of our total research budget is focused on pain.

It is always worth noting that NCCAM, unlike its sister research units at NIH, deals almost entirely with real-world, on-the-street-now issues of medical efficacy for therapies and healing approaches that have been used by the public for decades. CAM and integrative practices are already deeply embedded in that real world. These recent efforts to connect with the public are not easily constructed by a medical science research organization, so it is good, and timely, to see NCCAM expand its relationships with it most important stakeholders.

IOM President
Harvey Fineberg

In an article published this week in the New England Journal of Medicine, Harvey V. Fineberg, MD, president of the Institute of Medicine, presented a vision for resolving the pervasive and recalcitrant problems that plague what he “purposefully refers to a ‘health system’ rather than a ‘health care system.'”

But he buried his own personal advice to his colleagues at the far end of the piece. I’ve pulled it up for closer inspection.

Fineburg makes the health-vs-system distinction he says because: “Solutions need to focus on the ultimate outcome of interest…and not on the formal system of care designed primarily to treat illness.”

 A Successful and Sustainable Health System — How to Get There from Here at the New England Journal of Medicine.

Unfortunately his piece then plunges into four pages of distressing med-policy-leader-speak describing what he calls “our remarkably durable health crisis:” statistics, some trending positive, public investments, the much abused Accountable Care Act, agencies and entities in the health system enterprise all hard at work, etc.

If you can work your way through this predictable prose, you will come to the end of the piece and what sounds like Dr. Fineberg’s own personal exhortation to his fellow physicians:

Finally, champion a new ethos of medical professionalism that values accountability above autonomy; supports team-based care and interprofessional education; and accepts responsibility for a system to serve all patients, not only one’s own patients.

To achieve a successful and sustainable health system, we must be able and willing to try many different things. But therein lies a unifying idea: do many things. No single stroke will solve this problem.  A successful and sustainable health system —

• will not be achieved by supporting prevention,
• it will not be achieved by championing competition,
• it will not be achieved by comparing the effectiveness of different practices,
• it will not be achieved by striking commercial influence from professional decision making,
• it will not be achieved by changing the way we pay doctors, and i
• it will not be achieved by just reengineering the system.

It requires all these changes and more.

(I’ve bulleted the preceding points that were originally in a single paragraph.)

Removing the “it will nots” reveals an interesting pro-active prescription for those inclined to advance such medicine:

•  Support prevention
•  Champion competition
•  Compare practice effectiveness
•  Strike commercial influence from professional decision making
•  Change the way doctors are paid
•  Re-engineer the system

Would have loved to see the piece begin with these sentiments and flow outward into steams describing how each should be achieved.

I don’t know what happened earlier this year to draw the attention of the mainstream media to integrative medicine, but the subject has been batted around this spring among Forbes, The Economist — both of which expressed caustic disbelief that integrative medicine provides any benefit, and the Atlantic Monthly, which probes deeply into the sources for that disbelief to find that conventional medicine is broadly embracing integrative approaches.

Atlantic writer David H. Freedman’s long analysis, “The Triumph of New Age Medicine,” I summarized for The Integrator Blog; see a version below.  (TIB publisher John Weeks provides his own take on the article, from his perspective as a long time writer, analyst of and leader in the integrative practice community.  See his article here.)

A response to: “The Triumph of New Age Medicine”

Atlantic Monthly Magazine, July/August, 2011

This article is an important appraisal of the view of the future that the integrative medicine and practice communities can now see before them; even as integrative medicine itself has in recent weeks come under some conservative media skepticism from Forbes magazine and The Economist.

It is important because once you pass through the expected but decreasingly dense tangle of skepticism, writer David H. Freedman is able to highlight and describe in comprehensible fashion the aspects of integrative medicine and practice that have sustained their advancement and will continue to do so.

As a journalist, Freedman is interested in burrowing into the general assumptions of professional cultures whose work has great reach and great consequence.   He wrote the book, “Wrong: Why Experts Keep Failing Us-And How to Know When Not to Trust Them.”   Last November Atlantic Monthly published his eye-opening account on the work of meta researcher John Ionnides, MD, whose examinations of medical research in the 1990’s exposed a dysfunctional system and unreliable results (conditions that inspired in part the program for Comparative Effectiveness Research developed by the Institute of Medicine in 2009 as part of the American Recovery Act).

Freedman’s starting premise in this piece appears to be the question:
“How come alternative medicine is still here?”

The articles in Forbes and The Economist basically bark out a similar question, recounting what by now are standard objections to the adoption of anything “integrative:” there is no proof — no evidence-base; any alleged benefit is due to the placebo effect; these so-called practitioners are duping the public through slick marketing; medical schools condoning this are deluded; some of this stuff is downright dangerous; it is all quakery run amok.

For the general reader the piece includes a couple of unnecessary distractions, starting with the title phrase “New Age Medicine,” which no doubt Freedman did not compose.  Those words still retain powerful connotation for things way out of the mainstream: tie-dyes, a perpetual daze, the 60s, Drs. Cheech & Chong, and now marijuana clinics lining California strip malls.

Freedman also makes the decision to use “alternative medicine” throughout.   “Alternative” is an “instead of” term, which immediately sets the integrative and “real” medical communities on opposite sides of the room.   Had he used “complementary” the story would be more easily digested by the general reader and it would more accurately describe the current state of integrative and conventional relations.

It isn’t helpful, for instance, to suggest that a representative example of current integrative treatment might include “hologrammed silicone bracelets.”  But there it is, to capture the mind’s eye of the general reader.

So his story rolls out a little unevenly.  It is not unlike following a mosaic stretching through a gallery of 30 rooms, the images on the walls of each revealing a little more of an unfolding theme that will ultimately infuriate the critics.

An Alternative Medicine Portrait Gallery

Which means, as is most often the case with articles on this topic, the gallery trip must stop in the obligatory Quackaderium, where skeptics (including the author of Forbes’ critique) rain down aspersions on the qualifications, intention and motivation of integrative professions and on the “gullible” public to whom they are “marketing.”  Freedman eventually sets these assertions against the prevailing realities, but I wondered how many readers would reach this section and think “just more of the same,” and go back to email.

But on balance, the trip through Freedman’s gallery, reveals a collection of fairly-drawn portraits: on the questions of evidence and the apparent omnipresence of the placebo; the inadequacy of RCTs; the loss of healing sensibilities among physicians; real patients he observes in treatment; and the depth of integrative acceptance now in place in the most well known of conventional care institutions.  A few noteworthy observations:

• “To focus on alternative medicine’s placebo effect ignores what may be its largest benefit-its adherence to a ‘healing’ model of patient care.”

 

• “The medical community knows perfectly well what sort of patient-care model would work better against complex diseases… the promotion of a healthy diet, encouragement of more exercise, and measures to reduce stress.”

 

• “Every single physician I spoke with agreed: the current system makes it nearly impossible for most doctors to have the sort of relationship with patients that would best promote health.”

 

• “A medical system that successfully guided patients toward healthier lifestyles would almost certainly see its cash flow diminish dramatically.”

 

• “Other sorts of professionals could be better at the healing, bonding … and for less money. These might include behavioral-medicine therapists, social workers, nurse practitioners, or even some entirely new sort of practitioner specially trained for the task.”

 

• “But what’s the sham treatment for being a caring practitioner, focused on getting a patient to adopt healthier attitudes and behaviors?”  Citing UC Davis neuroscientist Clifford Saron: ‘…Science has to learn to listen in a sophisticated way to what individuals report to us.'”

 

• “Ultimately, what today’s medical students think about alternative medicine will be more important to the future of medicine than what anyone else thinks of it.”

Eventually the trip through the Freedman gallery takes him into the Mayo Clinic (literally), where his account of observations, conversations, and commentary reaches a kind of reality crescendo.  He writes:

This notion that alternative medicine is a legitimate response to mainstream medicine’s real shortcomings is one I heard, in variations, from everyone I spoke with at the Mayo Clinic.

That includes the assessment of the dean of Mayo’s medical school, Keith Lindor.

And your local Mindfulness, Yoga, and Meditation therapist?

Freedman here is interested primarily in the attitudes within the conventional medical establishment, so he does not address the growth and maturation of the specific complementary and alternative medicine (CAM) disciplines, such as acupuncture, Chinese medicine, manipulative and energy therapies.  The work of such practitioners and the educational institutions that have trained them, are also growing closer to the conventional care system: for instance in agreements between local integrative practitioners and nearby hospitals that are now adding wellness and integrative services.

Freedman’s overall assessment presents for general readers a view of a future in which medicine has changed substantially, through widely available integrative practices and attitudes that have been experienced and accepted by literally millions of individual clients over the last generation.  It is a history of health benefit simply no longer avoidable.  As Freedman quotes Mayo’s Lindor:

One of the most common complaints we see from patients is chronic abdominal pain, and we only figure out what’s wrong 10 percent of the time. These people deserve a chance to be helped by someone who takes a different approach.

As a practical matter, objections like those published in Forbes and The Economist will continue to appear, in part because — as one integrative medicine leader observed not too long ago — alternative medicine “…is like the environment and global warming. It is a cultural phenomenon: an argument you can’t win.”

Unlike the ozone, however, integrative practice occurs at ground level, and carefully researched articles like Freedman’s illustrate how the benefits of such practices are making their own argument and now have the ear of a sizable portion of the nation’s health community.

Jeremy McCarthy manages the worldwide spas of Starwood Hotels, where he works, as his Twitter bio says “…at the intersection of wellness, positive psychology and hospitality.”

He also writes a very insightful personal blog, The Psychology of Wellbeing
in which he draws on wide range of current developments in personal health, wellness and healing approaches and the science behind them.

In a recent post on his blog he told an interviewer from a spa consulting firm:

“My real interest is in holistic wellness. The reason I study and write about psychology is because I feel like that is the part that is undervalued in most health models. Even in the spa industry, where we talk a lot about ‘body, mind, spirit,’ we could do better at really understanding the science behind people’s mental and emotional states or their sense of meaning and spirituality.”

Spas with far more local clientele than Starwood have gradually been introducing healing therapies to their services and looking at the new generation of personal wellness tools now being developed.

In a recent report from the 2011 Global Spa Summit held in Bali (of course), Jeremy wrote: “One surprising trend that came up again and again in multiple sessions during the summit was the concept of personal biological monitoring—people using technology to keep track of their own health metrics.”

As he points out, these monitors and sensors are very early in their development. It is interesting to see where innovations like these are appearing and how wellness service providers like spas are broadening the context and value of their offerings. With 300 Starwood properties to worry about, Jeremy has a truly global wellness perspective from which to draw.

Prince Charles

Like Al Gore, who spent 25 years educating himself about the earth’s climate, the Price of Wales has spent years immersed in food and sustainability, including 26 years “farming” himself. Whether or not he turned the soil or pulled out the carrots, like Gore he has done considerable homework.   Through his foundations he has  initiated projects designed to address a global food system under serious stress.

His keynote is as good a summary as you will hear on the current factors in play across the planet that influence not just food production systems but the natural systems on which they depend. His analysis is tough and filled with data and research results. He also provides a thoughtful approach for encouraging more private sector engagement to resolve the status quo and return to “agri-culture, rather than agri-industry.”

Prince Charles keynotes "Future of Food" conference in Washington, May 2011

(To view the video produced by WashingtonPost Live, CLICK HERE.(The page opens with a 4.5 minute excerpt of the keynote. Select “Full Speech” for the full 43 minute keynote.)

Here is the text of Charles’ remarks (PDF for download; 36 pps).