by John Weeks
The Institute of Medicine (IOM) of the National Academy of Sciences announced on March 11, 2008 that it will hold an “Integrative Medicine Summit” on February 25-27, 2009.1
One notes these things. The IOM is considered by many to be the brains of US medicine. It can be a potent influencer of government policy, research directions and foundation giving.
Among the most significant of IOM’s recent contributions has been leadership, if belated, in raising awareness and stimulating action on medical errors and medical deaths.2 But the IOM cannot be altogether proud of its track record if it is indeed the brains of our over $2 trillion system: by the IOM’s own accounting, between 1/3 and 1/2 of costs are for care that is wasteful and likely harmful.3 Either the IOM is not usually asking the right questions, or the brain’s messages are not being effectively translated into action by the corporate body of US research, payment and delivery.
That’s context. The IOM took a significant step into the complementary and alternative healthcare world 3 years ago when it published the 337-page Report on Complementary and Alternative Medicine in the United States. The volume considers many themes, has much good in it, and has certainly influenced some academic behavior. But the report appears to have had as limited an impact on the appropriate uptake of integrative health care as the IOM’s more typical business has had in shifting the disastrous direction of the broader medical system.
How, then, might this IOM Summit be, instead of a regurgitation of materials already published, of optimal value to our system in crisis? I suggest these useful directions.
Focus on health care, not medicine
Those involved in “integrative practice” assert a new paradigm of clinical care which focuses on healing and health creation in partnership with patients. A multidisciplinary consortium of complementary healthcare educators formally asserts the value in “recognizing the intimate relationship between health, mind, body, spirit and environment, and emphasizing health promotion, healing, prevention and wellness.”4 The paradigm is actually an “alternative” to reductive and reactive medical models, not a “complementary” add-on. The IOM would set itself a more productive polestar if it valued this profound shift of culture and practice. The focus of the Summit should be changed to “integrative health care” rather than “integrative medicine.” The Summit is an opportunity for the IOM to actively engage a health-oriented paradigm.
Focus on all of the integrative disciplines, not just medical doctors
The integrative practice field involves many disciplines. Consumer use of mind-body, patient-centered practice is neither dominated by “medicine” (MDs) nor is most care delivered by MDs. Over 100,000 acupuncture and Oriental medicine practitioners, holistic nurses, chiropractors, naturopathic physicians and others deliver most of this new-paradigm care. Consumers create their own teams with various practitioners in central roles in different times. For the Summit to more deeply explore these other practices would be to respect the IOM’s own rubric from its 2005 Report: “… the goal of integrating care should be the provision of comprehensive care that is safe and effective, that is collaborative and interdisciplinary, and that respects and joins effective interventions from all sources.” There is nothing in the rubric that says an MD should be in the center of the integrative universe, or that organizing this around an MD is more effective or cost effective.
Focus on the potential value in the outpatient, patient-centered medical home arena, not just on inpatient “complementary medicine”
Most integrative practitioners work in outpatient environments. Yet the “integration” dialogue has focused disproportionately on how to add “complementary therapies” to hospital and tertiary care. Yet we know that populations with more primary, outpatient care have better outcomes at lower cost than those in which consumers directly access specialists and subspecialists and thus fall under the sway of their predilections for often unnecessary surgeries and procedures. The “patient centered medical home” movement, led by family doctors, osteopaths, internists, pediatricians and community medicine practitioners focuses on optimizing outpatient care. This movement purports to be interdisciplinary and values collaboration, teams and community. This is the natural fit for incorporating integrative practitioners and therapies. Can these disciplines advance the patient-centered medical home movement and thus help to right the gross imbalance toward inpatient care in our delivery structure? How might the outpatient movement gain by linking with these natural health care allies?
Explore how integrative practices can meet primary care needs
Despite what we know about the importance of primary care, the United States has an emerging, primary care shortage of huge proportions. Conventional medical schools are not turning out enough practitioners. The IOM team would be smart to focus on the ways the distinctly licensed complementary health care disciplines (DC, ND, AOM, direct entry midwifery) and holistic nursing and medical practices can help meet this societal need. We have models. Some states already include licensed natural health practitioners as part of their primary care mix. What special training, if any, should be required? In addition, do these integrative disciplines model a health-focused primary care practice which may have something to teach conventional primary care practices? Might the bio-psycho-social model benefit from integrative inputs?
Focus research questions on whole systems and whole practices for chronic conditions
Conventional chronic disease management already involves multiple inputs: pharmaceuticals, counseling, exercise, dietary advice, and etc. Integrative approaches and practitioners are similarly multi-agent, but with a shifted intent and an additional array of tools. The goal of such care is not to leave the whole practice of health creation for a magic bullet, but rather to partner with the patient in an ongoing way in health creation through the complexity and potential of patient-centered mind-body care. The single agent placebo controlled randomized trial is not a gold standard in this environment; rather, it is too often an obstruction. The research community needs its own paradigm shift to support this practice shift to whole system, whole person chronic care. A great contribution from this Summit toward long-term resolution of our nation’s medical crisis would be to have this IOM effort jump into this challenging research arena with both feet. Research on all chronic care will benefit from the integrative care workshop.
Focus on economic outcomes using whole cost accounting
Given the current crisis, the IOM would serve us to focus on areas where integrative practice may provide care which also limits the direct and societal cost of poor health. This exploration should be speculative: discover best practices and extrapolate where cost savings might be gained through bringing health-focused approaches and practitioners into the care continuum. The IOM team should leave reductive analysis behind. Merely comparing medical cost to medical costs of a given intervention dismisses the more expensive, global costs associated with health. Included here are, for example, would be costs associated with adverse effects of conventional treatment as well as the cost savings, to an employer, for instance, that may come of from a patient-centered, integrative healthcare encounter. The IOM team should take a lead from the environmental movement and embrace whole cost accounting.
The IOM’s Summit process kicks off with a meeting of its 11 member planning team later this week.5 The effort is being managed through the IOM’s executive offices and managed by Samantha Chao, MPH. Interestingly, Chao also directs IOM’s Forum on the Science of Health Care Quality Improvement and Implementation, which is co-chaired by former US Treasury secretary Paul O’Neill, MPA.6 This forum is charged with moving the system changes stimulated when the IOM courageously dropped the bomb on medical errors in 2000.
This agenda for the IOM Summit - openly exploring the potential contributions of all of the disciplines involved in new paradigm integrative practices as potential models – could be strategically useful as additional shock therapy to business as usual. Maybe medicine has something to learn from integrative practices on how to become “health care.”
1. See the IOM initiative at http://www.iom.edu/?ID=52400
2. See two IOM reports, To Err is Human (IOM, 2000) and Crossing the Quality Chasm (IOM, 2001)
3. From Waste to Value in Health Care. JAMA, February 6, 2008—Vol 299, No. 5, 568-571
4. Academic Consortium for Complementary and Alternative Health Care.
5. The team is listed at http://www.iom.edu/CMS/3809/52400/55177.aspx
6. The Forum is described at http://www.iom.edu/CMS/3809/38607.aspx
Additional articles by John Weeks: