New Bravewell Report a Goldmine for Those Intrigued by Integrative Medicine, Pandora's Box to Skeptics

Bravewell's report, "Integrative Medicine in America: How Integrative Medicine is Being Practiced in the United States," opens a treasure trove of riches for those intrigued by the emerging field.
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Reading through Bravewell's report, "Integrative Medicine in America: How Integrative Medicine is Being Practiced in the United States," opens a treasure trove of riches for those intrigued by the emerging field. One wanders through one display after another on how medical directors in 29 health system-sponsored integrative medicine clinics see value in their models of care. One sees the variations, and the similarities, across 20 clinical areas including chronic pain, gastrointestinal issues and integrative cancer treatment.

The report is beautifully laid out and accessible to most any reader. I personally enjoyed poring over data on the types of therapies and practitioners offered in these clinics for specific conditions. Where do supplements and pharmaceuticals rank in use by these centers as integrative treatments? In how many have chiropractors and naturopathic doctors been welcomed? What would a human being with a given condition who chooses such an integrative clinic most likely be offered?

At the same time, it was clear during the media briefing and from some responses since that this report from the Bravewell Collaborative of philanthropists in integrative medicine is not the document to convince the skeptical.

First the pleasures and uses. There are many. A principal goal of the report was to describe what the heck is going on in these clinics. The report's team sent out a survey then followed up with interviews, some onsite. I am a particularly interested reader. Ten years ago, when these clinics were first popping up, colleagues and I used a similar method with an early integrative clinic benchmarking project, in which we surveyed 27 such centers. Bravewell had it extensively in its original mapping study.

One useful question: center directors were asked to select the top five from a list of 20 health conditions that they "believed their practitioners treated most successfully with integrative strategies." Selected by 75 percent was chronic pain. This was followed by gastrointestinal disorders (59 percent), depression/anxiety (55 percent), cancer (52 percent) and stress (52 percent).

The report then opens windows on the kind of care one would receive for each of the 20 conditions via thumbnail sketches of the approaches in a few clinics. For chronic pain, for instance, strategies at integrative centers associated with Stanford University, University of New Mexico and the University of Colorado are featured. These demonstrate significant variation in provider mixes and therapeutic approaches. An appendix bores down further. Data show the number of centers that offer each of 34 selected therapies and practitioners for each condition.

Top therapies in use, across the board for all 20 conditions, are: food/nutrition, supplements, yoga, meditation, traditional Chinese medicine (acupuncture) and massage, followed by pharmaceuticals. These are integrative clinics. Conventional pharmaceuticals, and integrative consults by a medical doctor, are often part of the mix.

I found satisfaction on one of my opening queries. Of the clinics, 38 percent employ (full or part-time) chiropractors and 28 percent naturopathic doctors. Each marks a rough doubling of inclusion from my data 10 years ago. Chiropractic doctors were in just 19 percent of those 27 hospital-based clinics, naturopathic doctors in 15 percent. While many of these were different centers, the changing inclusiveness is remarkable.

The report begins with a useful introduction for any consumer who is not sure what to expect. Do these centers serve as primary care? Or do the providers principally serve in an adjunctive way, as consultants? Or are they do-it-all and comprehensive? These three types of service offerings are described. Not surprisingly, among these affiliates of large health systems "consultative" ranked at the top.

This finding points to an unfortunately misleading characterization in the way the report is presented. The subtitle is wrong. More fitting would be "How Integrative Medicine is Being Practiced in Health Systems in the United States." Left out of this document are the thousands of community-based practices of functional medicine doctors, naturopathic doctors, advanced practice holistic nurses, chiropractors and even practitioners of acupuncture and Oriental medicine who present their offerings, or those of their clinic groups, as integrative medicine or integrative healthcare.

My guess is that "primary care" would rise in the ranks of the type of model if all of these typically outpatient services were included. It would be useful to see these other forms of integrative medicine similarly examined.

Those curious about the business models and payment options will find a segment on reimbursement, and an appendix on what the authors call "Success Factors" for each of the clinics. I asked why the well-known role of philanthropy in integrative medicine was not featured more significantly in the report. Bravewell's president, philanthropist Christy Mack, rightfully responded first by noting that this is not unusual in medicine, saying, "Philanthropy is important in all forms of health care." Mack then acknowledged that the authors found that donated support is of continued importance in these clinics. She expected that this need for investment from the philanthropic sector would ease over time with more acceptance and coverage of integrative approaches and providers.

Skimming the success factors of each clinic reminds one again how much individualization and variation in these integrative medicine clinics are hallmarks not only of therapeutic approaches. These are also characteristics of the business models through which these clinic operators seek to secure a place for integrative medicine in these health systems.

And here's the rub for the disgruntled and skeptical. In the press conference, a member of the mainstream medical media asked why the study didn't provide "objective, uniform measures of outcomes" from integrative medicine treatments. His broader question was whether these integrative medicine approaches should be promoted without more rigorous science. The report is clearly intended as a promotional tool.

A participant in the study and in the media briefing, Donald Abrams, M.D., an integrative oncologist at the UCSF Osher Center, spoke to the research challenges: "In funding such research, we are talking about researching 'whole systems.' The [National Institutes of Health] is having trouble getting its mind around this. The NIH is a bit reductive."

Integrative primary care doctor Ben Kilgler, M.D., MPH, the chair of the Consortium of Academic Health Centers for Integrative Medicine (CAHCIM), chimed in that most of the clinics and their directors are involved in forms of research. (For those interested, the always-robust International Research Congress on Integrative Medicine and Health, sponsored by CAHCIM, will be putting much of that work, as well as discussions that seek to address the NIH's reductive predilections, on display May 15-18, 2012, in Portland, Ore.)

Kligler clarified that this study was never meant to be a report of outcomes. As research, this is descriptive. It is published as part of the Bravewell's long-term investment in mapping the field. As such, "Integrative Medicine in America" is very successful in answering questions for any consumer, policymaker or health professional who seeks to understand what is going on in these centers, and where their operators see that they have value to those who come through their doors.

As noted, the skeptics express concern that this kind of information may be used to shape integrative medicine's uptake. Never mind that much of what is done in conventional medicine is similarly shaped by what is typically practiced, rather than evidence.

No question: This document will be used in many decision processes by various stakeholders, including consumers. The report makes it clear that integrative medicine is alive, growing and as impossible to stuff back down through the eye of the reductive needle as it would have been for these whole system approaches of care to escape into public use if required to be forced through the prevailing NIH mind.

If these individualized, multimodal approaches are the new medicine and the healthcare of the future, as the Bravewell argues, the dominant mind at the NIH may be the most significant obstacle to us finding our way toward a health-focused system of care. But that is another story.

To many, opening this report will be to receive a gift generously given of new understanding of how to transform our disease-focused delivery organizations. To others, a mere peek inside emits evidence that Pandora's box has been opened for over decade. What diversity and opportunity -- or horror, depending on your perspective -- now infect our leading delivery organizations!

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