by John Weeks
On February 19, 2009 in a plenary session for the Integrative Healthcare Symposium, Josephine Briggs, MD will participate in a panel on the future of integrative practices. Briggs is arguably the most important single influencer in this future. Last January, she became just the second director and the first female director, of the NIH National Center for Complementary and Alternative Medicine (NCCAM).
The power of Briggs’ position may be best understood by reference to an ancient strategy of war. That strategy teaches that those who control the narrows of a river will control commerce and the countryside. For the future of integrative practice, research may be viewed as just such a narrows. The issue is not just with outcomes, but also the questions asked. Access, acceptance, integration, reimbursement, integration, the therapeutic order and much of the ability to transform lives are all downstream from this narrows.
Briggs brought a sterling NIH resume to her new position.1 She had not, however, much background in complementary, alternative and integrative medicine prior to taking on her role. She announced immediately that she planned to spend six months listening and learning, and to all accounts, she has. She has traveled the country to visit with researchers, educators and practice leaders from diverse disciplines. To her credit, Briggs also made time to meet with me in mid-March, despite an open letter I wrote at the moment of her appointment, which questioned NCCAM leadership from a scientist who was not already experienced in the field.
Now Briggs has begun to clarify her agenda for NCCAM. She plans some significant, if evolutionary changes. In this late October interview - a prelude to her Integrative Healthcare Symposium participation – Briggs offers her perspectives on the new directions NCCAM will take in her tenure.
Weeks: Thank you for the time. You announced in your first appearance with the NCCAM advisory council that you plan to do a lot of listening in your first six months. I am aware that this has been going on. Colleagues at Tai Sophia Institute in Maryland and Palmer Research Institute in Iowa and the massage-focused (Crossroads) clinic in the Beltway and numerous integrative medicine researchers have shared that you visited or opened your office to visits and input.
Briggs: I am continuing my outreach activity. Last week, I was at the American Association of Acupuncture and Oriental Medicine conference, meeting with a lot of terrific people. I will be with the Consortium of Academic Health Centers for Integrative Medicine in a few weeks. The listening continues.
Weeks: Are you closing in on your priorities?
Briggs: I have been struck by the fact that chronic pain conditions are major problems in health care – chronic back pain, joint pain, headaches. Honest conventional physicians will acknowledge that they don’t have all the answers, and many patients seem to benefit from various CAM approaches to managing these problems. We’ll be emphasizing research in these areas. We anticipate a new program solicitation for non-pharmacologic approaches to chronic pain management in 2010.
New priorities for NCCAM: effectiveness research
Weeks: What kind of general approach do you foresee taking?
Briggs: You will see us increasingly invested in real world, effectiveness-type of research. It’s important not just to look at research on mechanisms and efficacy trials, which might look at acupuncture versus sham acupuncture. I think that we need to look at things more broadly. We need to look at how effective some of these interventions are in creating better outcomes in settings that are as close as possible to the real world. There are healthcare implementation questions. You’ll see an increasing focus on effectiveness research.
Weeks: I would think that with a healthcare system as haywire as ours that this is an appropriate direction, in general. Ever since I read a JAMA editorial from some Institute of Medicine leaders stating that up to 50% of what we do is waste, and likely harmful, I’ve been dumbfounded that our research establishment is not redirected toward problem-solving this.2
Briggs: There was a recent NIH Directors meeting (involving directors of all the Centers and Institutes), where there was extensive discussion on the role NIH should play in effectiveness research. It’s fair to say that there is a recognition across the NIH of the importance of effectiveness research, and that we need to communicate more clearly what we are doing with the Congress and public. We think our portfolio at NCCAM is yielding information that is relevant, but that we have to be more proactive.
Weeks: Let’s talk numbers. What percentage of your research dollars do you think should have this more practical flavor?
Briggs: The most important factor in answering that question will be the outcome of peer review of the proposals we receive, so I can’t give you a direct answer. I will say that right now greater that 50% of our research involves human subjects and that percent will continue. Also, we intend to steer funds more actively in the direction of research on effectiveness of CAM approaches to chronic pain management with the initiative planned for 2010, and will also place a higher priority on investigator-initiated research in this area. Clearly the funding for this will have to come from money that was in other investigator-initiated areas. Some 10% of our funding is in large herb trials, for instance, and we are not currently planning to start any new large trials. This might slightly shift the balance, although we won’t abandon the natural products portfolio.
Review panels, journal reviewers and whole practice models
Weeks: An issue I have learned about from researchers who are interested in looking at the whole practices of integrative care, is that they believe a significant obstacle to getting whole practice research funded is reviewer bias. The issue seems to be that conventionally-trained NIH researchers are accustomed to the relative simplicity of a single agent drug trial. They give poor scores to trials which necessarily have more uncertainty involved since they involve multiple modalities. We joke that many would rather know something that is absolutely meaningless perfectly well, rather than something that is potentially very significant but is surrounded by some uncertainty.
Briggs: Review panels are rightly made nervous by complex trials in all areas of health research. We need to go into expensive, large-scale trials with strong evidence of promise and a lot of confidence that we’ll have a clear outcome at the end. We’d like to understand potential biological mechanisms in order to design large, complex trials, for instance. Research design has to be described well enough to be published in a scientific paper.
Weeks: I must add – not to whine but to point out what may be a structural challenge in bringing forward whole practice research – is that I have also heard that journal editor bias is quite like reviewer bias. Neither is comfortable with the real world uncertainties of multi-modality approaches.
Lessons from cognitive behavioral therapy
Briggs: I do believe that a more holistic, patient-centered approach is a major piece of the effectiveness work and will have to shape our research endeavor. But this research is not easy and CAM researchers are going to have to ask some hard questions. They are going to have to do a lot of protocolizing of their approaches, which involves some compromises. The field of cognitive behavioral therapy is a field from which we can learn in this regard. The field is about 10-15 years old and also employs complex, individualized approaches. In some cases the therapies are now accepted as the best, but this only came to be after the researchers got together and came up with protocols and carefully analyzed the approaches. This would be a direction for naturopathic research, to describe and define the practice in a way that can be researched.
Weeks: Another area of significant interest, of which I am aware through work with researcher colleagues in the Academic Consortium for Complementary and Alternative Health Care, is cost outcomes. Members of the professions out practicing in communities know that cost data are critical for expanding access. We talked about this when we met in March. Do you have plans in this area?
Briggs: Cost is certainly one of a number of important measures of effectiveness. When we met in March you certainly educated me on the importance of the issue of the costs of poor health and benefits of wellness over time to an employer. Presenteeism (a productivity measure) is a substantial cost. This is a valid point. We will see if it’s possible to assess costs in the effectiveness research that we do. From an NIH perspective, assessing effectiveness must be viewed more broadly than just cost, as our reason for doing research.
Weeks: Well, I’ll probably keep nagging you that cost be elevated on the NCCAM agenda. At least at this point, no other agency seems to be asking cost questions related to integrative practice.
Briggs: Clearly, there is no way that the issue of healthcare costs is not going to be important for the country.
Weeks: Thanks again for your time. I look forward to the panel in February at the Integrative Healthcare Symposium.
References:
1. http://nccam.nih.gov/about/director/
2. From Waste to Value in Health Care. Thomas F. Boat, MD; Samantha M. Chao, MPH; Paul H. O’Neill, MPA. JAMA. 2008;299(5):568-571.