Summary: No one doubts whether the Bravewell Collaborative's new mapping study added useful understanding of the nation's health system-sponsored and academiac health center-sponsored integrative clinics. But do these thumbnails, reports and tables on these 29 clinics capture what the title suggests: Integrative Medicine in America: How Integrative Medicine is Being Practiced in the United States? I posed the question. Here are responses from: public health acupuncturist and researcher Beth Sommers, MPH, LAc, PhD; holistic medical doctor Bill Manahan, MD; Integrator columnist Michael Levin; rehab specialist and past American Association of Medical Acupuncturists board member Mitchell Prywess, MD; an anonymous integrative MD; National University of Health Sciences president Jim Winterstein, DC; and senior editor of the Textbook of Functional Medicine Sheila Quinn. i conclude with my own speculations on what might be different in community-based integrative medicine.

The mapping study on the state of integrative medicine funded and carried out through the Bravewell Collaborative of philanthropists is a remarkable contribution to our knowledge of integrative clinical centers sponsored by health systems and in conventional academic medical settings. I posted my first take in the Huffington Post: New Bravewell Report a Goldmine for Those Intrigued by Integrative Medicine, Pandora's Box to Skeptics.

However, I was nagged by a question that I noted in the first piece: Does the report, widely covered in the media, misrepresent the whole field as its sweeping title suggests: Integrative Medicine in America: How Integrative Medicine is Being Practiced in the United States? The survey looked at just 29 health system-sponsored, and often medical school-sponsored centers. What of the literally thousands of other clinics and centers delivering "integrative medicine" of some kind? Thus this Integrator Forum: Does the Landmark Report "Integrative Medicine in America" Actually Portray Integrative Medicine in America? The query provoked a half-dozen responses. Here they are. I add some comments along the way and a table of my own quesses at the end.

Beth Sommers, LAc

1.  Elizabeth Sommers, PhD, MPH, LAc:

"Thanks so much for publishing the Bravewell Collaborative's report "Integrative Medicine in America". This represents an important first-step in identifying best practices and demonstrating the array and diversity of integrative approaches.

"At the Institute of Medicine conference in 2009 (‘Integrative Medicine and the Health of the Public'), there was a lively debate about how these practices should be described. ‘Integrative health' can be inclusive of a spectrum of practices - some of which are modalities administered by trained, licensed providers, and others which are self-help activities that might include lifestyle factors involving nutrition, exercise or stress reduction.

"Although the jury is still out regarding what to formally call this collection of practices, as a public health advocate I prefer to use the term ‘integrative health'. This nomenclature allows us to explore a larger slice of activities that include community-based practices that may occur outside the realm of academic medical centers. One example of this might be the National Acupuncture Detoxification Association, which has created hundreds of centers world-wide that address issues of recovery from chemical dependency. These services occur on reservations, community health centers, mental health facilities, homeless shelters, military veterans' clinics, and prisons. Another pivotal sector to poll includes nurses who've incorporated a variety of therapeutic approaches into their scope of practice.

"For the next stage of a report on integrative health in America, I'd like to see a broader and more representative slice of integrative practices. As you suggest, polling practitioners of integrative modalities would be one way to address this. There are also many hospitals across the country that offer access to some of these practices, but do not formally consider themselves as providers of integrated care.

"Appreciating the spectrum of integrative approaches amplifies our understanding of health and, more importantly, puts the emphasis on education and self-empowerment for consumers."

Mitchell Prywess, MD

2. Mitchell Prywess, MD:

"Great question, John. The report & your inquiry are both timely.

"As one of the 800 AZCIM graduates, who practiced a form of Integrative Medicine for nearly two decades with no additional Integrative Medicine credentialing (other than eventual Medical Acupuncture certification in 2000), I am invited to address a group of Naturopathic Medicine students at the University of Bridgeport to discuss Integrative Medicine and share my own personal insights.

"Am I not preaching to the choir, in this regard?

"It would appear to me that as more traditional Western trained physicians come on board to lay claim to the practice of Integrative Medicine (popularized by Dr. Andrew Weil), we will need to explore how this burgeoning field within academic medical centers and health systems integrates well with those community-based practitioners. My hope is that rather than a 'turf battle' that can potentially isolate practitioners (i.e., Medical Acupuncture vs. the majority of acupuncturists, who are non-MDs), we find a way to work together so that everyone benefits, especially the patients we serve.

"Having said that, I am a long time supporter of Bravewell's efforts, and very pleased that this report was published. It certainly offers the majority of allopathic physicians, who have no idea of what Integrative Medicine is about, a lens into the future direction of Medicine & healthcare that they need to learn more about."

The unspoken assumption is that the dominant player needs no modifier. Yet the "conventional Consortium" allows room for others, as does "allopathic physician." A good way to lay Prywess course away from the turf battles is to not lay claim, with our language, to turf that is not one's own.  

Michael Levin

3. Michael Levin: "This disciplined subset of integrative medicine is amenable to research and quantification"

Integrator adviser and columnist Michael Levin has served in executive capacities for both conventional pharma and natural products firms. His passions in integrative care focus on cost issues, incentivizing wellness, and product quality. He presently consult with a variety of entities.   

"Thanks for surfacing Bravewell's exceptionally well-crafted and sorely needed report. Great stuff!

"Does this report actually portray integrative medicine in America? No, this simply does not broadly represent 'Integrative Medicine in America' but rather a very important segment of integrative medicine in America. To their credit, the authors acknowledged the limitations in scope, which may be more accurately defined as:  'Integrative Medicine as Practiced in 29 Conventional-Medicine Centric Health Systems.' 

"And that's perfectly OK. Unlike 'Integrative Medicine in America', this disciplined subset is far more amenable to research and quantification. Thanks to Bravewell's great work, we now have a current,  data-driven view into one important corner of the 'amorphous Integrative Medicine breadbox.' Measurement is the first step in the march towards best practices."

Comment: It's true, I don't expect money from the Bravewell. This is not because of this column, however. Rather, Bravewell has made it clear that as a group they only fund projects led by medical doctors. The agency I work for is not. They do what they want, of course. I would hope that we are all big enough to realize that one can both celebrate the good that an organization does (as I do in my two prior pieces, and here) and also offer criticism. Monoculture weakens the genes, doesn't it?     

Bill Manahan, mD

5. Bill Manahan, MD: "There is a completely different world of integrative medical care being practiced in private offices

"Your question is:  Does this portrait capture what a consumer is likely to experience - or what you as an integrative medicine practitioner offer? Is the field appropriately represented here? Does the report misrepresent? What would be different if such a report were based on surveys of community-based practices? 

"My answer is that the portrait does represent how integrative medicine is being practiced in MEDICAL CENTERS and HOSPITALS across the U.S. So, if we interpret the words in the article's title - Clinical Centers - as Medical Centers, then the report does what its title claims it does, and, therefore, does not misrepresent.
 
"But, no, the Bravewell Report does NOT represent how integrative medicine is being practiced in thousands of medical offices around the U.S.  There is a completely different world of integrative medical care being practiced in private offices, and most of those physicians are not connected to a medical center or hospital.  What those physicians do in their practices goes well beyond what is occurring in most of the practices described in the Bravewell Report.
 
"It would be wonderful if Bravewell would now write a new report based on a survey of physicians practicing in private practices.  They could easily get a list of those physicians by going to the American Association of Naturopathic Physicians, American Holistic Medical Association, American College for Advancement in Medicine, American Academy of Environmental Medicine, American Academy of Anti-Aging Medicine, Institute of Functional Medicine, Age Management Medicine Group, and a few others.  The portrait of those practices would be different from much of what is described in this Bravewell Report.
 
"In 2010, I visited 25 such practices, and my findings were published as a guest editorial in Explore: The Journal of Science and Healing, July/August 2011, Vol 7, No 4, pages 212-214, titled, "The Whole Systems Medicine of Tomorrow: A Half-Century Perspective."  There was an art and a science practiced in those integrative medicine clinical settings that embodied the best of allopathic medicine practices and added the multiple elements of integrative holistic medicine that significantly raised the bar regarding patient satisfaction and outcomes.  It was a powerful and moving experience for me to observe the various physicians practicing medicine in a manner that I am quite sure will someday in the future be considered normal and routine. And, interestingly, the physicians satisfaction rate regarding enjoyment of their practices was an astounding 4.4 on a scale of 1 to 5.  They loved what they were doing, and so also did their patients.  I discovered that there is a way for physicians to have fun practicing outpatient medicine and at the same time help people achieve health and healing."

"It seems logical to me that in those states where the ND's have some pharmaceutical prescribing ability, they are the ideal integrative practitioners doing integrative medicine. Their basic training for four years is primarily integrative medicine. Those of us trained in allopathic medicine have the majority of our training in acute care medicine, and then we have had to learn integrative medicine along the way during our years of practice. Sometimes that works and sometimes it is probably not the best way to learn. Admittedly, we are now beginning to have some good training programs for MD's and DO's in integrative medicine so that is good. 
 
"I do think that the ND's would benefit (and enjoy it) by requiring a two-year residency after their four years of ND school.  One year would be with an MD or DO in a primary care office and the other year would be with an ND in his or her office practice. 
 
"At the same time, what I envision for many primary care practices are small clinics in which MD's and DO's work side-by-side with ND's so each of them can do what they are trained to do best."

Jim Winterstein, DC

7. Jim Winterstein, DC: "An interesting read, but so what?"

Jim Winterstein, DC has over 40 years in the chiropractic field. He is president of National University of Health Sciences where he personally has a practice right that includes acupuncture and his program in chiropractic medicine educates a broad scope chiropractor. He is a regular Integrator commentator.

"It was an interesting read, but so what? Conspicuous by their absence (mentioned but not in the main roles) are naturopathic and chiropractic physicians.

"The most frequently employed (full or part-time) practitioners at the integrative medicine centers in the study are physicians, followed by acupuncturists, massage therapists, meditation instructors, dieticians/nutritionists, and yoga instructors."

"The Bravewell Organization has fallen into the same tired litany so often used by the allopathic profession. 'Physicians' are ONLY those with the MD or DO credential and ALL others are simply one kind of 'technician or another.' Well, its nice that 'physicians' have granted these 'technicians' some role in 'integrative care,' but for me, at least, the reality is no different than it was when I was an x-ray tech in the sixties. Decision makers are MDs and all others 'do as they are told.'  It would be my guess that NONE of these 'technicians' would even be in the picture, and, in fact, there would be no 'integrative medicine' at all, if it were not for the public pressure of the past decade or so, and to a degree, even that seems to be waning.

"I think it is telling, however that once more allopathy has managed to simply usurp the 'tools' of some of what they would call 'allied health technicians' and use them to buttress their own fortifications (allopathic temples of 'healing' called hospitals), while keeping complete control of patient care. Its ironic that oriental medicine is an entire system of healing with a complexity that rivals anything about Western allopathy and it has been around for several thousand years and yet, allopathy has such a grip on our society that it can simply relegate it to the position of 'technician.'

"The report is interesting, but that's about all as far as I am concerned."

Comment: Quinn's IFM piece focuses on the dearth of outcomes being analyzed in these 29 health system sponsored clinics. Despite their relative bandwidth, the analyses of patient experience are not emerging. While Quinn does not focus on how these clinics may differ from communikty-based functional medicine practices, she cites the definition of "integrative medicine" in the Bravewell study then adds:

"All of this is important and, happily, functional medicine already encompasses these values and goals. What’s missing from the definition, however—and what functional medicine offers to all practitioners, regardless of discipline—is continually evolving mechanisms and tools for seeking the cause of disease and dysfunction and for individualizing care. Using a systems biology approach, the functional medicine matrix and associated tools make it possible to implement integrative medicine strategies in a systematic, consistent, and effective manner. Without those elements, it will be very difficult to 'help people regain and maintain optimum health.'"