| | My Meeting with the U.S. Leader for Complementary and Alternative Medicine Research | |
Summary: Early in March, I received an invite from Josephine Briggs, MD, the incoming director of the NIH National Center for Complementary and Alternative Medicine (NCCAM) to meet with her at the NIH. I had forwarded my Open Letter and some of the comments from readers and shared that I wouldn't be far from Bethesda on other business in mid-March and would look forward to a chance to meet. Briggs made time. We met on Friday, March 14, 2008. Here is a report from that meeting plus some input from my Integrator advisers.
When I first wrote about the appointment of a new director at the NIH National Center for Complementary and Alternative Medicine (Oops, They Did It Again: An Open Letter to New NCCAM Director Josephine Briggs, January 24, 2008), I offered myself, and others, as resources to Briggs. Inexperienced in the field, she needed to get up to speed, fast. Integrator discussion revolved around the extent to which actual experience of integrative, holistic, whole person and health-oriented interventions is critical for informing the vision that will provide optimal leadership in researching new paradigm approaches. Many readers have weighed in with strong opinions. Issues arose, also, about the experience of other key staff members. (See links to related articles, below.)
On March 14, I had a 50 minute meeting with Briggs. She had Richard Nahin, PhD, MPH, NCCAM’s chief health services fellow, with whom I'd become acquainted at a conference in 2000 on issues in "practical applications" at which we'd both spoken. We met around a small table in Briggs office.
What follows is a report I originally prepared for my Integrator advisers. They are an extraordinarily diverse group to whom I'd emailed, 36 hours earlier, for any ideas they had about what subjects I might broach. Their responses (see the bottom of this report) I'd arranged in a file which I believed I
had sent to Briggs the night before I arrived. I handed her a hard copy of the brief bios and photos of these advisers so she'd have some faces and background to go with the comments.
Unfortunately, I apparently did not send the articles ahead of time. I did speak with her
about a number of these advisers' comments, and I have sent them to her since. When I sent off the following to my Integrator advisers, one suggested I publish it. Here, with minor changes, is that report.
______________________________________
My Experience
of Dr. Briggs
I
found Dr. Briggs quite welcoming. She appeared to be open to ideas (see below). My
sense was of a person developing a passion for the questions and the field. We
had some points of disagreement, some give and take. I felt like she was ready
to learn. I did not discover if she is actually extending her educational
process to experiencing the therapies/practitioners, etc. Sorry to say, I didn’t ask the
question. I liked her.
My
approach to the session
Bill
Manahan, MD [an Integrator adviser] wisely suggested ahead of time that I approach the meeting more like Barack Obama (listening)
and less like Hillary (already full of answers). I consider Manahan a mentor and I have plenty to learn. That said, I am often not such a good
student. There was plenty of Hillary in the room. I justify myself this way: I
see my role in some ways as advocating for those in the “practical applications”
side of this research dialogue – integrative practices, hospitals, payers,
employers, individual practitioners. I had been told ahead of time, by adviser
Christine Goertz Choate, DC, PhD, among others, that Dr. Briggs would be in a listening mode, so I did
spend more time advocating than asking.
The
make-up of the NIH National Advisory Council for CAM
Some
of you may be following this: NCCAM is wildly out of compliance with some 17%
from CAM disciplines when it should be 50% plus. [See
NCCAM Out of Compliance with Mandated Advisory Council Make-up: IHPC and ACCAHC Urge Correction .] NCCAM however is of the
(legal) opinion that they are meeting it. She did not think that this
make-up issue was very important. I expressed that she is working with
populations that have been excluded and are quite sensitive to inclusion
issues; and that it was important to have perspectives of people raised into
these whole practice approaches. I went so far as to speak the parallel with
the exclusion of women. Yet she clearly didn’t think this was an important area
for focusing our time – noting that there would only be 3 new people selected onto the council in 2009.
NCCAM: Feeling
pressure from "both sides"
Briggs noted that one of the challenges at NCCAM is that there are people actively opposed to
the very existence of NCCAM. [See Is NIH NCCAM Sailing into a Perfect Storm? October, 11, 2006] To these detractors, as I have learned, it is important the
NCCAM’s advisers have long, conventional resumes, and look like advisers for
other Institutes. At the same time, others (like me) are arguing that NCCAM
bring in people who are relatively new to the research game, but who can bring
the wisdom of whole practices to the table. It is a tough spot. I noted that I
have come to NCCAM’s defense in the Integrator and will again. She noted
that a person with whom she’d met earlier had told her that I viewed myself as
“loyal opposition” and I told her that this is so. We agreed on many areas where NCCAM needs to be focusing; we have differences in prioritizing the questions that
NCCAM should be asking.
 Whole
systems/whole practices
She
was aware of, and interested in, this area but tended to focus on a process of
slowly building understanding around meaning of “whole system” and of tools
that might capture special integrative medicine outcomes rather than quickly
prioritizing or promoting this direction, as I and many of (my advisers) would prefer. Interestingly, Nahin noted that there had been a 2001
NCCAM program offering on whole systems and that NCCAM hadn’t had much of a response.
This was news to me; I had no idea. He sent me the link immediately after the meeting Briggs
seemed to see whole systems as a process of growing an initiative step by step.
I felt, in retrospect, that I have made the mistake of not more clearly using “whole practice” language, as used by former NCCAM advisory council member Carlo Calabrese, ND, MPH, which
to me is a more finite, presently do-able, undertaking.
Employers
and global costs of health
Thinking of how to serve employers, discovering their questions, was new ground for her, and pretty new for Nahin – especially the important
concept of "presenteeism." We had an interesting exchange about how some employers are
realizing that up to 50% of global costs are presenteeism or productivity-related, and that
those costs may be very conducive to change via CAM/IM/mind-body approaches. I
suggested NCCAM convening a meeting at some point which would bring employer researcher types
and NIH folks together, looking at measures and what each viewed as important.
I suggested that this might have the added benefit of creating a supportive
constituency of large employers for NCCAM, should NCCAM ever be seriously threatened. (US Senator Tom Harkin and others might be impressed if health and productivity managers with the likes of Chrysler and Ford Motor and John Deere were showing up to advocate for expanding NCCAM's budget.)
Briggs seemed interested in the topic. She thought the convening would be 2-3 years out. I liked her openness in this general
area. I felt that she too saw where work with things like employee “energy” and
“focus” and “depression” and “functionality” and backing off certain meds and
quality of life were places whether a lot of CAM-ish approaches might prove to
be valuable. She showed awareness of the employer world in stating that, if big
employers want to test something, they typically don’t go through NIH’s encumbered
processes, but instead just go after it on their own. I noted that I knew of at
least one case where a large employer thought moving something from an internal
pilot to an NIH funded trial would he useful (the Ford/acupuncture story with
which Integrator adviser Kenneth Pelletier, PhD, MD (hc) is involved). Her point is generally correct in my
experience.
A
Center for Medicaid and Medicare Services pilot?
At
one point she noted that she might like the idea of a program in which there
was partnering with Center for Medicaid and Medicare Services (CMS). I noted that among the adviser comments I was submitting
to her were some specific comments (from Richard Sarnat, MD, the Alternative
Medicine Integration Group re their Florida Medicaid pilot). This is an
interesting potential direction.
Why
she has so $120-million plus to work with …
I
enjoyed a sharing a story – given to me by adviser Peter Amato, whose firm,
Inner Harmony Group is an Integrator sponsor – about the vote on the
Senate floor a few years back to support the first huge jump in NCCAM funding.
Peter – who has politically supported Arlen Specter (R-PA) substantially over
the years, had argued strongly for the increases in prior meetings with Sen.
Specter. Peter was in the audience, seated with Andy Weil, MD at the moment
that the vote was taken. Specter gestured to Peter and Andy before pushing the
increase through. Briggs smiled appreciatively.
Big
picture – the limits of the (typical) mind of the NIH
We
had a global exchange in which I shared the overview that, as a medical
culture, we’d gone from a focus on acute disease to chronic disease and now
more acute are back but we never really did very well with chronic. She seemed
to agree with the general view. I suggested that the mind of the NIH was formed
in the acute era, finding single agents to go after acute problems, the Pharma
model – but that the mind of the NIH had never really changed to admit what we
know about chronic disease: these have multiple origins and thus, common sense
would say that an intervention would also have multiple “whole person”
dimensions. Isn’t NIH missing the boat? She seemed to agree about how the mind
had been formed, and that there might be something here. I was making the case
that they customary mind is an obstacle to cure.
I subsequently sent her a
great little piece adviser Vic Sierpina, MD co-authored with John Astin, PhD in Academic
Medicine which looked at the uptake into practice of biopsychosocial
practices, and specifically mind body practices, via surveys of med students
and residents. (Integration of the Biopsychosocial Model: Perspectives of Medical
Students and Residents; Acad Med. 2008; 83:20-27.) The theme is very supportive
of what I was trying to communicate. Astin/Sierpina noted in the text that
despite 30 years of mounting evidence for a (whole person) biopsychosocial
model, the total hours devoted to it in a typical curriculum were something
like 40/7800 – a stupendous failure to respond, failure to let go of the
reductive and biomedical in medical schools which we are also witnessing in the NIH. Again, I found her open to these kinds of probes, if not necessarily moved by them.
Parallel Universes: Wherever
I lay my hat down, that’s home
Ultimately,
I was struck by the facts of our very different lives over the last 25 years,
hers and mine. My home is out here, in the messy world of practical
applications of things, with the kinds of loose dimensions that necessarily
shape the work. She, meantime, has been deep inside the research industry which
has its own rules and mores. Wiser people than I have thought and written about
the peculiar relationships between our (not so) ivory towers and the dirty
murky worlds of real life they are supposed to assist. My general sense was
that, when the heat of an exchange would subside, she would relax into what she
knew, and I into what I have come to know, and that these are almost parallel
universes.
I continue to think as I did when I wrote the Open Letter that it is
in the blood, in the body, in the spirit experience of integrative and natural
care which is the most likely to spring the best research questions, most
likely to bridge between these universes and ensure that NCCAM has
significance, and is secure. Interestingly, the Astin/Sierpina paper found that
it was those students and residents who experienced the treatments and used
them in their own lives who were most likely to do what science recommends
and recommend mind-body approaches with their patients. I urged her, again, in my follow-up letter to her, thanking her for the meeting, to
include experimentation and experience in her learning process.
Thank
you [advisers] all for your prompt responses. I entered the room feeling the strength of
all of you. Now, it would be nice to go back and be Barack, and just interview,
and ask questions. I believe the time for that will be after this period of
her fact-finding and learning.
______________________________
Responses of Integrator Advisers to Requests for Comments
As noted, I asked my Integrator advisers for their ideas prior to the meeting. Some hit reply all, so there is a little exchange here. Some just responded to me. I wasn't clear that I would be publishing, so did not get an okay to have names attached and therefore publish these without attribution.
#1
I guess my thoughts would
be a bit different from trying to figure out what questions to ask her about
CAM and research. I would first want to praise her and thank her for
inviting you to meet with her. Then I would spend whatever time it took
to find out who she is, what does she want, what are her dreams and
aspirations, and how can the group of us on The
Integrator Blog advisor group be of service to her. In other words,
it is what I do with my patients when they come to me asking for advice.
I try to get to know them and figure out who they really are. Once a
relationship is established, then what occurs in the future will have more
meaning to both of you. In other words, approach this meeting more
through your heart and spirit than through your brain. Being it is such a
political time, I might say to approach this meeting as a Barack rather
than as a Hillary.
#2
1) What is NIH's appetite
for research into exploring cost-offsets associated with CAM interventions in
high-cost, widespread disease states (eg, obesity, dyslipidemia, depression,
etc)?
2) If there is an appetite,
what is the likelihood of such research being done...and when?
#3
Tell her I like [the 2 questions immediately above], X2. I would also suggest queries as follow:
- Relative priority on
“whole system” studies e.g. TCM, Tibetan medicine, Ayurveda
- Specific intentions
regarding herbal medicine
- Perceived importance of
studies on chronic disease in general and pain in particular
- Perspectives on obesity
#4
1) How to best continue
NIH funding, either U19 , R21. R01, K awards for CAM and conventional schools
for CAM research?
2) How best to build
across disciplines high impact collaborative studies of CAM
3) In general, how might NGO's like the(Consortium
of Academic Health Centers for Integrative Medicine and the Academic Consortium
for Complementary Health Care) work together top support NCCAM's and NIH's 5
year plan.
4) Others are relative to educational
standards, policy and reimbursement, patient centered care, patient safety and
implementation of IOM and WHHCAMP recommendations.
#5
1. Report on and actions from the NCCAM Research
Issues meeting last spring
2. Her vision, focus, priorities
3. Possibilities for interdisciplinary team and
cluster studies
4. New approaches for study of holistic
phenomena
5. Healing environment and healing culture
studies.
#6
Prioritize the scientific exploration of CAM whole systems medical
practices and principles through a program designed for these
projects. Such studies may yield important, even perhaps
revolutionary, insights into the nature of health and healing e.g: TCM's
"qui"; Ayurvedic, naturopathic and homeopathic constitutional
medicine; biomarkers for suppression and the healing reaction in
naturopathic medicine; the therapeutic order, Hering's rules of cure, and
return of old symptoms in naturopathic and homeopathic medicine.
#7
[One other] has some
good questions. I look forward to hearing her perspective. I might add a query
about the role of industry in all this. We represent an important financial
resource which brings an associated bias but we might still be a valuable
resource in the big picture. We also have a vested interest in claims
associated with interventions which is probably a bigger topic than time
permits.
Specifically, we are
frustrated by the fact that our model for integrative chronic pain was very
successful for the state of Florida to the point that all parties have agreed
to expand the number of lives managed. Yet, as we attempt to deal with
CMS and move forward with the expansion, various budget concerns keep raising
their ugly head, despite the fact that we have already proven to them that we
save them significant dollars for every life we manage. Obtaining
additional funding to expand the program as an ongoing integrative model in a
real-life community setting for research purposes would be very helpful.
If she can identify an appropriate grant writer for this project and keep an
eye on it, would be helpful.
#8
1. Budget for bundled
interventions evaluated in RCTs. Given IOM report re: this need.
2. Resources dedicated
toward eval 'placebo'
3. How will she/we strategically
address pressure from within NIH and outside (Wallace etc) to remove funding.
#9
I have a few requests:
1. Licensed professional acupuncturists to have a
role in developing policies and designs.
2. Continue supporting qualitative inquiry.
3. Continue collaboration grants between CAM and
conventional institutions.
#10
When is the
evidence now demonstrated by complementary and alternative approaches to
healthcare going to fully be recognized and incorporated into not only research
funding but into the health care system? How can this prestigious office
now begin to incorporate CAM providers from marginal to mainstream, from
afterthought to first-line consideration? What would the research agenda
look like if it were perfect?
#11
I
would be interested in hearing about the NIH ability to provide whole system
research or develop pilot projects in concert with CMS. In other words would
there be a possibility to develop a bridge between CMS and NIH to partner with
a pilot project. The reality is CMS just put the kybosh on a DM project with 7
different DM vendors. Guess what - they did not show savings. My reality is
that relationship oriented health delivery goes a long way toward promoting
behavioral change. I am convinced that utilizing lower cost holistic providers
to provide attended therapies combined with literacy interventions is a cost
effective way to promote real behavioral change.
Bottom
line we can overlay all types of disease management techniques but most is for
naught if the patient does not change behavior... The white coat syndrome exist
in a very real way with most DM ventures, that's why there is a significant
regression to the mean. However, the whole person approaches that value
relationship development and human exploration of self are the types of systems
that can have life changing components for patients which result in better
outcomes, self management, patient adherence to treatment regimens and lower
cost. I would very much like the opportunity to prove that with a CMS
population. Old people need love too ya know!
________________________________________________
Coda: I received some quick responses from a number of my advisers when I sent this to them. Adviser Bill Manahan, MD, a former president of the American Holistic Medical Association, co-founder of what is now the American Board of Integrative and Holistic Medicine, and clinical faculty at the University of Minnesota School of Medicine sent a longer note. This seemed a good place to complete this report:
"Thank you, John, for
your detailed reporting of your time with Dr. Briggs. It almost felt
to me as if I were in the room with you.
"I especially appreciated
your last couple of paragraphs. The limits of the NIH mindset are
profound to those of us who have been clinicians most of our lives, and that
NIH mindset tends to be the opposite of what Vic Sierpina and John
Astin discussed in their fine Academic Medicine article.
"And I also
thought your last paragraph was right on. Not only are the lives of
so many of the people in research different from those of us "in the
trenches," but the basic world view of the basic
researcher tends to be quite different from those of us who
primarily do patient care. Yes, there is occasionally some crossover
(I see Wayne Jonas as a good blend of both), but different minds
and personalities migrate to different types of jobs. In some ways, the
difference is as marked as the present difference between a Democrat and a
Republican. The world looks very different depending on whose eyes
through which it is viewed.
"Anyway, keep up the good
advocacy."
Bill Manahan, MD
Minnesota
Other related articles:
Oops, They Did It Again: Open Letter to the New NCCAM Director, Josephine Briggs, MD
Your Comments: 12 Voices on NIH Appointing, to Direct NCCAM, a Scientist Inexperienced in CAM
NIH NCCAM Responds to Integrator Open
Letter Regarding Briggs Inexperience
Your Comments Forum: Additional Perspectives on the Appointment of NCCAM's Inexperienced Director Josephine Briggs, MD
3 Voices on NCCAM's Transition: Mind-body Pioneer Achterberg, AOM Student and Anonymous Academic Researcher
br>
Send your comments to
[email protected]
for inclusion in a future Your Comments Forum.
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