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.

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).

US Sen. Tom Harkin of Iowa has been the primary Congressional paladin for the integrative medicine and prevention and wellness community since the early 1990′s, when he personally cajoled the Congress to create the Office of Alternative Medicine. In the subsequent 20 years, integrative therapies, modalities, and approaches to care have become far more accepted across the conventional care landscape, including in hospitals and care facilities and in medical schools.

Here Harkin addresses attendees of the April 2011 iMosaic Conference in Minneapolis, and brings viewers up to date on this journey, describing where the Affordable Care Act defines integrative health practices and the major initiative to advance a National Prevention Strategy in which integrative practices can play an important role.

French Hospital MC
San Luis Obispo, CA

As the following example illustrates, the public is increasingly being presented with examples of the use of integrative medicine practices with conventional treatments for conditions like cancer in sessions like this hosted by a local hospital like French Hospital Medical Center.

Of interest in this presentation is the participation of a medical oncologist from a conventional cancer treatment center, a naturopathic physician (ND), a chef/nutritionist, as well as a survivor.

Panel to discuss integrating natural remedies with western medicine
March 29, 2011
via KSBY News
(San Luis Obispo, Santa Barbara, CA)

Integrating mainstream cancer treatments with natural remedies will be the topic of discussion later this week at French Hospital Medical Center.

A panel of experts will talk about western medical oncology, treatments with naturopathic support, and therapeutic food choices: Integrative Medicine and Cancer Care.

The panel included:

• • Thomas Spillane, M.D., Medical Oncologist with Coastal Integrative Cancer Care and Medical Director of the Heart Cancer Resource Center;
  • Dr. Tod Thoring, N.D. with Pacific Natural Medicine;
  • Nancy Walker, Certified Natural Chef and owner of The Wellness Kitchen in Templeton, CA;
  • Shannon D’Acquisto, a five-year breast cancer survivor and a mother of three who incorporated integrative cancer care into her cancer treatment plan.

The free program was open to the public: held on March 31, 2011;  for information at (805) 542-6234.

Integrative oncology is becoming a specialization in itself.  For more see the Society of Integrative Oncology web site.

Related: the National Cancer Institute has been studying the potential beneficial affects of food on the biology of cancer.   “Back to the Garden? NCI Studying Food and Genetics.”

They are starting with their athletes but have designed with the whole neighborhood in mind.

Our vision is that on any given day, a student in a 9th grade PE class, a math teacher, a mom, the school librarian, a varsity football player and a fire fighter from the station down the street will all do the same Workout of the Day.

See Saratoga’s Crossfit Sawmill page.  And more on Fitness-Based Learning in the next post.

Students work out before class. Click to view PBS report on fitness and learning.

“It’s all about the heart rate.” Paul Zientarski, who has recreated PE at Naperville (IL) Central High School, tells us this: and when student heart rates go up in the hour before they sit down in class, their grades will follow.

In addition to the brushfire of school nutrition initiatives emerging in schools all over the country, we are seeing the connection between physical fitness and cognitive fitness put in place at the other end of the building.

Paul Zientarski

The PBS program “Need to Know” focuses on the work Zientarski is doing in Naperville, and the research John Ratey MD is doing at Harvard that points increasingly to the importance of physical education and fitness in general on the optimal function of the brain.    For Zientarski, the results are showing up in the academic performance of students who participate in specific exercises in the morning before class.

John A. Ratey, MD

Ratey, the author of the book “Spark,” has reported research that showed morbidly obese teens can have IQs as much as 30 points lower than their peers.   He also notes that “fitness-based exercise programs” are definitely not “gym.”  The new understanding of the effect of fitness on cognition is just beginning to be applied in school settings like Napierville.

These school days there is so little availability of phys ed in schools — only 2% of high schools provide daily physical education — that the advance of illnesses arising from being overweight and out of shape are becoming too predictable and in the case of the US Army, limiting the number of candidates able even to go into basic training.

These transitions are well described in a recent report funded by the Robert Wood Johnson Foundation, “Workplace Clinics: A Sign of Growing Employer Interest in Wellness.”

It observes:

The focus has shifted largely to health promotion, wellness, and an array of primary care services, rather than occupational health or convenience care.

(The RWJF information page with a link to the report is here:

The report was produced in Dec. 2010 for RWJF by the Center for Studying Health System Change in Washington DC, which a spokesperson told me does not focus on integrative medicine or practice to any degree.  But, as with the emergence of Comparative Effectiveness Research in 2009 and 2010, transitions in traditional workplace health-related approaches are responding to significant shifts in society and in market demands and expectations.  In the case of employment settings the primary focus is on the control of health care costs.  As a practical matter, one means to that end appears to embed in employer health clinics approaches from the integrative experience.

Integrative Health Practitioners’ Presence Increases

For instance, the report refers repeatedly to the skills and approaches considered central to integrative health: health coaching, nursing, primary care, attending the whole person, clinicians who “provide compassion” and “spending more time with the client.”  Many of these reflect the recommendations of the compelling “Wellness Initiative for the Nation” (WIN), formulated by the Samueli Institute, Alexandria, VA in 2008. (Links to this report are here.)

Consider this assessment from one of the third party companies that have historically created and/or operated workplace health clinics for businesses:

Of all the RFPs that have come to us in the past 24 months, I can’t recall one that didn’t ask for wellness and health promotion.

Wellness and health promotion of course are terms that can cover a wide range of intentions.  This report cites the following types of clinical services in place or being designed for new worksite wellness programs:

Occupational health—treatment of work-related injuries, employment physicals and screenings, travel medicine, and compliance with federal workplace safety regulations.

Acute care—ranging from low-acuity episodic care, such as sore throats or sprains, to treatment of more severe symptoms requiring urgent attention, such as exacerbations of chronic conditions.

Preventive care—physical exams, immunizations and screenings.

Wellness—health risk assessment follow up, biometric screenings, health coaching, lifestyle management programs and educational programs.

Disease management—ongoing care for and management of chronic conditions.

One on hand, something of the usual suspects.  The section on “Staffing and Recruiting” however more directly describes these trends in hands-on terms:

“Clinics focused exclusively on wellness,” the report notes, “tend to have health coaches and other professionals with varied backgrounds, such as nurses, health educators, nutritionists and exercise physiologists.”

The report notes that large enterprises such as Dow Chemical, “…have developed more limited in-house clinics with an almost exclusive focus on wellness programs.”

Some individual integrative practitioners are also taking the initiative to sell their services into the legacy occupational health service providers that have long-established relationships with business clients.  A yoga therapy practitioner in New York, for instance, has just started to approach such providers.   Local hospitals that have been providing integrative therapies and wellness programs for their own patients could be in position to take that new expertise to local businesses.

This increased focus on wellness and health promotion is also changing the role of clinical  health professionals.  This is perhaps the primary point of intersection for the integrative community.  As one medical director put it:

“The challenge was that we had occupational nurses trained a certain way, and everything was about work injuries. … Over time we need a new skill set to deal with the person as a whole person.  Some providers were able to make that jump, others were not.”

The report also notes that in some cases even the omnipresence of the MD is also becoming less critical.   A corporate medical director said of nurse practitioners: “The reason I like NPs is they have to do care planning in school and learn to treat the person as a whole; physicians tend to think about (discrete) problems.”

This phenomenon has had another curious effect according to the report: the company clinic is seen as a lower-cost, convenient option, especially for primary care, and the lines are a lot shorter.  “People who otherwise would not have sought care may suddenly flock to the clinic,” the report says.

MyCompanyMyHealth.com  ?

This growing emphasis on wellness and health promotion corresponds with the employer’s   increasing role as a source of health information.   A February 2011 study from the membership organization the National Business Group on Health reports that in 2010 75% of workers used their employer for medical and health information, up from 57% in 2007.   (A press release with links to the report are here.)

As others have pointed out, the obvious downside to a concentration of the employer’s role in health affairs is that any value it might provide benefits only the employees of businesses who can afford such programs.   Developments like this usually rankle integrative practitioners who are concerned with ensuring far broader access to healing therapies.  But these trends also present opportunities to further establish the credibility and efficacy of integrative services.

Just as the new Comparative Effectiveness Research regime represents a response to research conditions that were many years in the making, the rising interest in wellness and prevention is also no sudden phenomenon.   Although not yet very well known, the integrative medicine research community now has significant historic data on efficacy and cost-saving factors that will continue to make the case for adding integrative approaches to clinical services being considered for corporate wellness programs.

The report covers other important factors, including the practical issues of how wellness programs are licensed in the states, how the IRS treats prevention benefits, and how the Affordable Care Act (if it survives the year) may provide $200 million in grants to businesses with fewer than 100 employees for wellness programs.   It is one of a plethora of reports on the transitions of health responsibilities and solutions in the workplace, but worth a look for how it describes the thinking and approaches now finding favor there.