by John Weeks
Three recent encounters with initiatives in “integrative medicine” strongly suggest that this field will increasingly be viewed as an MD subsidiary unless remedial action is taken to affirm a more inclusive role for non-MD integrative medicine professionals.
I am not sure what to think about this.
The first encounter was a review of the instructional course provided by the newly re-minted American Board of Integrative Holistic Medicine.1 The certification, which is only for MDs and DOs, is reasonably enough also only taught by MDs and DOs. The second encounter was similar, a review of Integrative Medicine, the influential 1238 page text developed by David Rakel, MD. Of the 100+ authors, 97% are also MDs/DOs.2, 3
The third is the National Summit on Integrative Medicine and the Health of the Public, co-sponsored by the Institute of Medicine of the National Academies about which I wrote here last month. (3) The 12-person planning committee includes 9 individuals with clinical training. 100% of these are MDs. Of the other three, one is a PhD researcher, one a consumer, and one is listed as a vice president of an acupuncture school.4
Bradly Jacobs, MD, MPH, an integrative medicine leader formerly in academics who is now a senior editor and blogger with Revolution Health5, provides a persuasive argument for why this mono-sourcing of teaching, and leadership, makes sense. In a response to a review I wrote of Rakel’s book, Jacobs describes the use of MD/DOs authors or teachers of MDs/DOs tactically: “I would argue that you are more likely to consider something different from what you are accustomed to/trained in if you hear it from ‘one of your own’.”
Jacobs knows Rakel’s predicament well. Jacobs is co-author and co-editor of The ACP Evidence Based Guide to Complementary and Alternative Medicine, soon to be published by the guild for internist MDs, the American College of Physicians.
“Let’s be honest with ourselves. People are fearful of what they don’t know or understand. You have to meet them where they are. That means hearing it from someone who shares the same professional training, and speaks the same language, etc. They are far more likely to consider something different from what they know under these circumstances.”6
Notably, both Jacobs and Rakel are known to be personally supportive of multidisciplinary integrative medicine teams which include diverse complementary healthcare practitioners. In fact, Rakel invited 6-7 naturopathic physicians to write; only one responded. For his part, Jacobs worked with the Academic Consortium for Complementary and Alternative Health Care on some content on the complementary healthcare disciplines for his book’s appendices. Yet the contributor section blinks MD-MD-MD in neon.
The human logic for this MD-centrism, as asserted by Jacobs, is compelling. If one seeks to transform the practice of 750,000 medical doctors, then a core healing approach might be to meet these professionals where they are, square in their MD-centered universe. This like-treating-like approach may be an especially important therapeutic strategy if the patient happens to be a profession which has had its exceptionality drilled into it through a decade of medical schooling and a societal backdrop of a century of white-coating of these practices.
For one reason and another, by intention or by accident, the trend witnessed here is for “integrative medicine” to increasingly be seen by professionals and the public as a practice by, for and about MDs.
Maybe this is fine. If that is what we mean by it, would need clarity that it is only MDs/DOs we are talking about, plus or minus an MD’s ancillary use of other practitioners, when we say “integrative medicine.”
If we accept this, then those who wish to be more inclusive of all the integrative disciplines might wish to drop this term and use, instead, the phrase “integrative practice” (as used here on this site) or the similarly ecumenical” integrative health care” or “integrated health care.” Each of these labels is discipline-neutral. Any number of practitioner types, including integrative MDs, fit under those umbrellas. In addition, by speaking of “practice” or “health care,” these terms avoid the reductive, disease-focused, MD-centrism which is associated with the term “medicine.” These terms are aligned with transformations toward multi-disciplinary respect and health creation.
Yet ceding “integrative medicine” to MDs could prove harmful to the emerging, corrective, medical pluralism which the integrated healthcare movement also represents. Practitioners of naturopathic medicine, acupuncture and Oriental medicine and chiropractic medicine (a term favored by a subset of chiropractors) were all offering forms of patient-focused, mind-body, whole person “integrative medicine” long before the term “integrative medicine” was coined in the mid-1990s. To cede the term “integrative medicine” to the MDs would effectively accept the view of the “Scope of Practice Partnership” of the American Medical Association which fights against a medical scope for other disciplines.7
To allow “integrative medicine” to become an MD franchise would also quickly deplete the potential number of integrative medicine professionals. The total of licensed NDs, DCs, AOM practitioners, direct-entry (homebirth) midwives and holistic nurses is roughly 100,000, far out-numbering the total of MD practitioners of “integrative medicine.”
Agreement on what we mean by “integrative medicine” is increasingly important as the dialogue over “alternative medicine” shifts beyond “complementary and alternative medicine” (CAM) and is increasingly denoted by “integrative medicine.”
The ND, DC, AOM and holistic nursing disciplines would be served to clarify their views through position statements on whether or how they view their practices as “integrative medicine.” Are they “integrative medicine”? Once they have their sense internally, they might let the integrative medical doctors know.
MD/DO leaders could also clarify their self-definition. “Integrative medicine” as defined by the Consortium of Academic Health Centers for Integrative Medicine, the organization with 41 medical schools as members, is not definitive on whether “integrative medicine” can be practiced by members of other disciplines.
Integrative Medicine is the practice of medicine that reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches, healthcare professionals and disciplines to achieve optimal health and healing.8
Yet the Consortium’s membership requirement that only institutions that educate MDs/DOs can join appears to trump the openness of the definition. Since the organization is exclusive, one might assume that the definition is. Unintended exclusivity could be resolved by the insertion of “by any healthcare professional” after “practice of medicine.” Such an amendment would affirmatively recognize that “integrative medicine” is not the exclusive bailiwick of MDs/DOs.
Including these 4 words would deepen the declaration – already present in the Consortium’s definition – that “integrative medicine” requires respectful involvement with other disciplines. This addition would signify that “integrative medicine” represents a distinct break, in this sub-sector of medicine, with the AMA’s ongoing campaigns to dominate other disciplines. The addition would be a kind of affirmative action.
Working out these relationships, these definitions, is important if those involved in “integrative practice” are to become a significant force in a transformational process. Our job is enormous. The Institute of Medicine’s own assessment is that perhaps $1-trillion each year of what is done is medicine is waste, and much of the excess harmful.9 Actions that help distinct disciplines unite in the shared purpose of health creation would seem to be recommended.
References
1. www.holisticboard.org
2. For a review of Rakel’s book; http://www.jabfm.org/cgi/content/full/16/3/267
3. For my own review of Rakel’s book: http://theintegratorblog.com/site/index.php?option=com_content&task=view&id=472&Itemid=189
4. For the IOM Planning Committee http://www.iom.edu/CMS/3809/52400/55177.aspx
5. Jacobs’ blog is at http://www.revolutionhealth.com/blogs/bradlyjacobsmdmph
6. Jacobs’ quotes are from a response to an article at www.theintegratorblog.com
7. For recent AMA SOPP activity, go to http://theintegratorblog.com/site/index.php?option=com_content&task=view&id=470&Itemid=189
8. For the definition: http://www.imconsortium.org/cahcim/about/home.html
9. http://jama.ama-assn.org/cgi/content/extract/299/5/568
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