An NIH program to research your hot-tub claims...

I have long witnessed a profound disconnect between integrative, whole person-oriented practitioners and the research agenda at the National Institutes of Health National Centers for Complementary and Alternative Medicine (NCCAM). Happily, an NCCAM program approved in September creates an opportunity for this breach to begin to be healed.

A typical scenario in the estranged NCCAM-integrative clinician relationship goes like this. An NCCAM-funded researcher announces results of a randomized controlled trial of St. John’s Wort. The results are negative. Yet practitioners who routinely use the botanical change nothing in their clinical practices. That’s not the way I use it in my practice. I don’t prescribe it by itself. I use it as part of a whole treatment protocol.

In short, the theory being tested doesn’t reflect what the integrative practitioner would have claimed. The researcher may be speaking to other researchers. The clinician’s practice is not altered. Over time, a feeling sets in: Why follow what NCCAM is doing? It’s not about my practice anyway.

Origins of the NCCAM-integrative practitioner disconnect

When I think of the origins of this disconnect – beyond the typically slow uptake of research by clinicians - I like to imagine a commonsense, non-political scenario which, had it been followed, might have diminished this researcher-clinician alienation.

On January 28, 1993, mainstream medicine was shaken up by a study in the New England Journal of Medicine which showed that a third of consumers used some form of "unconventional medicine." This famous study, led by David Eisenberg, MD, out of Harvard, found that there were more visits to these unconventional practitioners than to all conventional primary care doctors. In my imaginary scenario:

Researchers immediately wished to learn what was going on here. They thought: Why not ask these practitioners? So researchers located these unconventional practitioners and listened to them talk about their practices and patients. The researchers thought: These practices are new to me. Let’s start our exploration by finding out where they identify value.

Now in this scenario, the intrepid researcher actually removes the pens from the pocket pen holder. He or she removes more than that and enters the hot-tubs at the natural settings favored by acupuncturists, naturopathic physicians, holistic medical doctors, holistic nurses and other integrative practitioners for the conferences. The researcher listens for what relaxed integrative practitioners say, or boast, even, about their outcomes. Certain themes surface in the researcher’s notes.

They say that – when they are successful - their patients feel better and enjoy life more. They say their patients can often do things they couldn’t before. They become more functional. The patient can be more productive. They say they partner with their patients. They say that their unconventional approaches can limit or remove their patients’ pain. They say that they can sometimes lower needs for powerful pharmaceutical which have significant adverse effects. Their patients begin to have more energy. Patients start making healthier choices. They say that they can often limit the need of their patients for certain more expensive procedures and surgeries. They believe they can save money over conventional services.

An NIH program with structure and outcomes closer to home

This common sense approach is not what happened. Rather, the thrust of research on complementary and alternative medicine inside the NIH has been to reduce these complex integrative practices. Researchers have sought to break the experience down into the bite-sized chunks which the randomized controlled trial (RCT) research apparatus of US medicine is trained and equipped to study. Instead of learning the language and assertions of this "unconventional" world, the researcher-clinician dialogue was dominated from the beginning by the research community’s dominant tongue: RCTs. In 2006, only 0.64% of all NCCAM funds supported effectiveness or cost-effectiveness studies.

Happily, NCCAM is slowly waking up to the limits of projecting a pharmaceutically-derived, reductive research strategy on practices which have multiple dimensions. On September 5, 2007, the National Advisory Council of the NCCAM gave the thumbs up to a new concept paper. The purpose is straight out of my imaginary scenario: "stimulate the development of observational studies to evaluate the effectiveness and cost-effectiveness of CAM approaches as used in the community."

In short, NCCAM finally has a program which is tailored to capture your hot-tub claims. You can show effectiveness and cost-effectiveness in (your) community setting.

Those of you who have been frustrated, like me, by NCCAM’s focus on reductive, controlled trials will want to read the concept paper just to see this fingering-wagging warning: "Clinical trials are NOT permitted and will be considered unresponsive and returned without review." What a turning of the worm!

Form partnerships to take advantage of the opportunity

NCCAM deserves congratulations for birthing this baby. Yet my excitement is accompanied by anxiety. While this new baby stirs hope, it is born into a less than hospitable environment. Can you in your practices, or your schools and professional associations, find research partners who are skilled in formulating these research designs? How, especially since the lack of funding of such paradigm-appropriate research has stifled the development of a cadre of experienced researchers?

Success in making these whole practice outcomes a useful norm at NCCAM will depend on activism from the integrative practitioner community. We must continuously urge NCCAM to nurture this new direction with tools and training to develop this new cadre of researchers. The new scenario is a good one – but it will still take a community to raise this child.

Links: