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NCCAM: Does It Live Up to Its Congressional Mandate? Not Even Close . . . plus more
This column is offered in collaboration with The Integrator Blog News & Reports (http://theintegratorblog.com), a leadership-oriented news, networking, and organizing medium for the integrative medicine community. For more information on these and other stories, enter keywords from the articles in the site’s search function.
Time for NCCAM to Comply With the Research Direction Congress Prioritized
During 2010, the National Institutes of Health (NIH) National Center for Complementary and Alternative Medicine (NCCAM) will be creating its third 5-year strategic plan. This will be the first under director Josephine Briggs, MD, who began her tenure in January 2008. The plan is expected to govern an anticipated total of $600-million plus in Congressional appropriations to NCCAM from 2011 to 2015. An NCCAM white paper* used to invite public comment calls attention to 3 sections of the 1998 Congressional act, which is supposed to provide the overarching framework for NCCAM’s direction. However, significant questions have arisen as to whether NCCAM met its mandate from Congress on how to prioritize expenditures while under Stephen Straus, MD, its first director from 1999 to 2006. My analysis of the 9 sections included in that powerful 2-page act of Congress that is the NCCAM mandate found a shocking misalignment of Congress’s apparent intent.† NCCAM presently focuses on basic research (more than 50% of its budget expenditures) and randomized controlled trials (RCTs, some 10%-20%), with just a minor fraction spent on outcomes or cost analyses of CAM or integrative health care (0.4%-1.1%). Yet, in birthing NCCAM, Congress repeatedly told the agency to analyze not agents but “prevention modalities, disciplines, and sys-
tems.” In addition, NCCAM was charged with evaluating how to integrate these with conventional medicine and its “delivery systems.” Such answers do not come from basic research and are poorly explored with RCTs. In order to guide NCCAM toward real-world questions, Congress deemed that NCCAM’s advisory council specifically was to be dominated by clinicians (>50%) plus consumers (18%), rather than by research wonks. One entire section of the document explicitly tells NCCAM to evaluate the licensed CAM disciplines. In case NCCAM needed further clarification, one section specifically states priorities by type of research in this order: 1) outcomes research, 2) epidemiological studies, 3) health services (including costs), 4) basic research, and then 5) “other.” NCCAM appears to have reversed this order to reflect typical NIH priorities. Notably, leading professional organizations representing integrative practitioners—from holistic medical doctors and naturopathic physicians to yoga and massage therapists—have weighed in resoundingly on the side of the effectiveness agenda. Comment: For the last 15 years, my work has focused on the practical matters of health care integration, whether in payment systems, community clinics, employer productivity strategies, hospitals and health systems, or, most recently, education in the health professions. Thus, I have been acutely aware of how NCCAM’s expenditures under Straus did little to evaluate outcomes or assist with the process of understanding how best to integrate medicine. Reading Congress’s mandate is infuriating. Had NCCAM done what Congress charged, the research infrastructure for CAM and integrative medicine would presently be dominated by scientists with specialized skills in outcomes, effectiveness, and costs. As it is, NCCAM has bred a look-
alike pod of researchers who are now invested in doing things in NIH’s typical fashion rather than focusing on the more important issues for consumers and integrative stakeholders: namely, when do I use these CAM modalities, how do I use them, what will it cost, or will I save money should I use them? Briggs, who has shown some interest in such realworld outcomes, needs to let Congress and the stakeholders they represent be her guide rather than the NIH club. She needs to dedicate at least 50% of NCCAM’s budget to doing what Congress prioritized. And even with that, in any unprejudiced reading of the mandate, the amount still falls short of compliance.
IOM president Harvey Fineberg, MD, states, “Like a Rorschach blot, the notion of integrative medicine, or integrative health, means different things to different people.”
Semantic Lines Being Drawn: “Integrative Medicine” and “Integrative Health” in Use by the IOM, Harkin, Holistic Nurses, and NCCAM
The debate over whether integrative health or integrative medicine is the best term to describe the broader movement of which this publication is part continues to percolate and shift—as also discussed by Bill Benda in his BackTalk this
*No authors listed. NCCAM’s mandate and mission. Updated October 20, 2009. NCCAM: National Center for Complementary and Alternative Medicine. Available at: http://plan.nccam.nih.gov/index.cfm?module=paper1. Accessed December 7, 2009. †Weeks J. How NCCAM’s “real world” Congressional mandate is optimal for NCCAM’s 2010-2015 strategic plan: respond by November 30! Integrator Blog. November 6, 2009. Available at: http://theintegratorblog.com/site/ index.php?option=com_content&task=view&id=606&Ite mid=189. Accessed December 7, 2009..
Integrative Medicine • Vol. 9, No. 1 • Feb/Mar 2010
Harkin had not responded. “Like a Rorschach blot. This is the first time medical use matched what AMTA has called “feel good” uses. 1 • Feb/Mar 2010 15 . 2009. Recommendations from the EST are due in July 2011. the later phrase dominates on the closing pages of the summary document. rather than on a specific profession. MPH. cosigned by 24 nurse associations. This particular “Rorschach blot” has a great deal of power attached to it. the quasipublic Weeks—Industry Insights Integrative Medicine • Vol.org). And the IOM listened. specifically called for “replacing integrative medicine with integrative health. IMCJ earlier reported that opinions about these terms were aired during the Institute of Medicine’s (IOM’s) robust February 2009 National Summit on Integrative Medicine and the Health of the Public (see “Special Report: The Institute of Medicine’s Summit on Integrative Medicine. struck a balance. Some attendees and speakers suggested that the summit would have been more appropriately and inclusively denominated as a summit on integrative health. the American Holistic Nurses Association (AHNA) sent US Senator Tom Harkin a May 5. Margaret Chesney. holistic care throughout the state. The paper uses the MD-centric “integrative medicine” 8 times in a relatively lengthy description of the emergence of the field. CRN represents large industry players in the supplement business. has assumed the executive director position at the Hawaii Consortium for Integrative Healthcare. the National Center for Complementary and Alternative Medicine) to the National Center for Integrative Medicine (NCIM). without reference to other preferences or other integrative practices. a nonprofit. Chesney also remains a principal player with the nonprofit Institute for Integrative Health (www. Yoga therapists are distinguished from yoga teachers by positioning themselves as addressing health or medical conditions. up from 64% in 2008. Notably.issue (see p 64). means different things to different people.2 Tweet along with new media entrepreneur and writer Taylor Walsh on his integrative medicine Twitter. multistakeholder organization committed to promoting wellness and advancing the practice of integrative. he used “medicine” 4 times and “health care” 3 times. 2009.8. For example.” The letter. is the new director of Integrative Medicine at the influential University of California at San Francisco Osher Center. with strong implications around inclusion or exclusion. and broadens the array of disciplines involved in promoting it. Of these. Rachel Wong.org/Integrative-Medicine. MD. the moderator of the closing panel. with a similar percentage saying that they’d used massage for relaxation or stress reduction. Comment: During the summit. The AHNA replied that “in transforming the health care paradigm. Fineberg states. The International Association of Yoga Therapists (IAYT) has announced creation of the IAYT Education Standards Committee (EST) to recommend entrylevel standards for the profession. PhD. 9. the notion of integrative medicine. an October 2009 NCCAM white paper regarding NCCAM’s next 5-year strategic plan. IOM president Harvey Fineberg. it seems from the looks of the final section of the IOM’s report on the summit. 74% say they have not decreased the amount of their use despite the economic recession. MD.1 The report of the 13th-annual survey on consumer use of massage from the American Massage Therapy Association (AMTA) found that 32% of the 1001 individuals surveyed had used massage in the past 5 years for medical or health-related reasons. Thus. letter upon hearing Harkin indicate that he planned to work to change the name of NCCAM (again. Margaret Chesney.tiih. No. referenced above. CRN found that 65% of 2043 adults are using dietary supplements. At deadline for this column. Go to http://tweepml. Michael Johns. The Consortium is unique in that its array of stakeholders includes many member organizations—from practitioner groups to hospitals and governmental agencies. a shift in language can be a critical influence in supporting and adopting that change. Use for both was higher among those with more income. “The use of integrative health and health care focuses on people’s health and well being.” The group urges that NCCAM be renamed the National Center for Integrative Health and Healthcare (NCIHH). Those on Twitter may be interested to know that integrative health and new media entrepreneur and writer Taylor Walsh has developed a list of integrative medicine–related Twitterers.” IMCJ. ShortTakes Supplement use is growing marginally amidst “complicated economic times” according to the Council for Responsible Nutrition (CRN) 2009 Consumer Survey on Dietary Supplements. or integrative health. former deputy director of the National Institutes of Health National Center for Complementary and Alternative Medicine has taken over as director of the Department of Integrative Medicine at the influential University of California at San Francisco Osher Center. showed no evidence of tension around terminology.” 3 In his brief foreward.3:20-29). PhD. further stated.” Indeed. In the second sentence of his “Foreward” in the November 2009 IOM publication that summarized the Summit’s proceedings (Integrative Medicine and the Health of the Public: A Summary of the February 2009 Summit).
founder of the Arizona Center for Integrative Medicine. even aficionados of the integrative practice dialogue frequently distinguish between all of the “other” practitioners and medical doctors by referring to the latter as “physicians. 2009. Comment: One day. holistic nurses. acupuncture and Oriental medicine practitioners. and finally. 1 • Feb/Mar 2010 Weeks—Industry Insights . below. I side strongly with the IOM’s shift. †Weeks J. 9. The new paradigm is about a health approach. Weil blasts the fail- ure of the current debate to focus on “the content of health care. 2009. That is to say. ACA’s efforts to restore DC physician status in federal health plan successful. yoga therapists. when the ACA celebrated its lobbying success to maintain physician status in the Federal Employee Health Benefits Plan. require insurers to cover health promotion and integrative care. we are going to need some extraordinary coalitions. He has clearly contributed immeasurably to the advancement of integrative practices of all kinds. teach health promotion and integrative medicine at medical schools and residency programs. Contained within are some interesting examples of how health care practitioners distinctly licensed as complementary and alternative are gaining stature in the pecking order of labels used for health care professions. October 2. Diverse state statutes also allow the term to be used by chiropractors or naturopathic doctors. Yet conscious and unconscious resistance to this language change will likely outdate such recognition in language. since no guild presently owns the term.4 In materials supporting publication of his recent policy-focused book. MD.” The importance of associating the physician term with the chiropractic medical profession was underscored recently by the American Chiropractic Association (ACA). ACA: American Chiropractic Association. Excluding whole categories of practitioners and practices does not inspire activism from them. create a National Institute of Health and Healing at the NIH and fund it generously.04 is listed as “Naturopathic Physicians. Integrator Blog. and others. No. 2009. (See discussion on the Weil book. 2009.” Yet trend lines say that. To be blunt. his reach with consumers has certainly shown up in the form of cash-paying clients of NDs.) MDs. The US Department of Labor’s use of the physician appellation supports an indirect practice of the US Department of Education that recognizes accrediting agencies in both these disciplines. has issued a set of recommendations for “true health care reform” and has put out a call to build a movement for change. Eight views on Andrew Weil’s seven recommendations for true healthcare reform: major ND Response.” The American Association of Naturopathic Physicians boasted of its success in working with the Department of Labor to create this positioning in an October 14. Weil on True Health Care Reform: A Call to Action and an Odd Paradox Influential author and integrative medical-education pioneer Andrew Weil. 2009. administered through the national Blue Cross-Blue Shield association.* Profession #29-1199.agency—considered by some to be the brains of US medicine—was won over to the new term. Available at: http:// theintegratorblog. And if we are ever going to make significant change. popular use is likely to eventually blur the type of practitioner who will be addressed as or will respond to the label of physician. after all. it appears to that we may be moving into a time where more practitioners are physicians. September 29. Weil’s book and the movement he supports may presently be limited in its impact due to an odd paradox in his work.acatoday. and law as it applies to CAM professions. From the 2 trends on language just discussed.† Comment: Weil’s recommendations are bold.1011 titled “Chiropractors” notes that sample titles of these practitioners include “Chiropractic Physician” and “Physician.org/press_css. Accessed December 7.php?option=com_content &task=view&id=593&Itemid=1. Dr. each of which notes that graduates may call themselves physicians. Why Our Health Matters: A Vision of Medicine That Can Transform Our Future (Hudson Street Press. However.com/site/index. including integrative medical doctors.cfm?CID=3583. establish an Office of Health Education within the US Department of Education. indeed. just as it is presently outdating changes in the education. on the side of the more inclusive term.” He then offers 7 recommendations “we can demand immediately” that he believes will drive the health care debate in a more substantive direction.onetcenter. promote.” Among job titles for this profession are “Naturopathic Physician” and “Physician. His platform is one that I suspect most of us can. 2009).org). and with the nurses. 16 Integrative Medicine • Vol. Andrew Weil. regulation. which replaces the Department’s Dictionary of Occupational Titles. NDs and the Use of “Physician” in US Department of Labor Definitions The US Department of Labor recently published O Net Online (http:// online. massage therapists. These are to ban direct-to-consumer marketing and advertising by big pharma. Available at: http:// www. (An * Lukacs C. create an Office of Health Promotion within the US Department of Health and Human Services and fund it appropriately. note to its members. The language under section 29. DCs. has jumped into the health reform arena. MD . Weil has issued a set of recommendations for “true health care reform” together with a call to build a movement for change. but what they do is not integrative medicine but integrative health care. Accessed December 7. Webster will be called to clarify that the term physician can refer to any of a number of health care professionals. He’s laid his name and money on the line to help NDs and others. “learn how to take care of yourself!” A discussion forum on Weil’s recommendations showed broad alignment but with one caveat expressed by naturopathic physicians that Weil does not appear to be actively promoting the potential contributions to improved health from NDs or other distinctly-licensed practitioners of natural health care.
Weil argues that “integrative medicine” will be the agent of change for medicine. . Available at: http:// www. Council for Responsible Nutrition. No authors listed.amtamassage. Available at: http://www. and that both you and your clients are saved from unnecessary risks. Available at: http:// www. you will receive the peace of mind that comes from knowing the supplements you sell are of good quality . American Massage Therapy Association. empowering stories from cancer patients and much more! $39. A health care call to action. and he will begin to more powerfully advocate for all the professions we need to engage to form the coalitions necessary for this change.95 plus shipping and handling ONLY Distributed by CELESTIAL ARTS/TEN SPEED PRESS To order this and other great health books.) Yet at the same time. 5-page form. DEFINITIVE GUIDE TO CANCER IS NOW AVAILABLE! REGAIN AN A CTIVE L IFESTYLE ! The ﬁrst layperson’s guide to using natural nutritional supplements to support conventional cancer therapy. 2009.indd 1 12/16/09 2:50:23 PM Weeks—Industry Insights Integrative Medicine • Vol.org. He can be reached at email@example.com. label information important purchasing factors. Cancer_HalfHort. Accessed December 7. . Accessed December 7.crnusa. Clinicians are requiring verified quality control. a veteran of integrative medicine publishing for more than 25 years. 2009.example: Weil made a significant grant to support a leadership conference of the Academic Consortium for Complementary and Alternative Health Care. 4. Weil does not celebrate all of the potential contributions to health creation from CAM practitioners. 2009 Massage Therapy Consumer Survey fact sheet: massage is used more than ever for medical/health reasons. Weil: Your Trusted Health Advisor.com. Notably. No authors listed.html. Accessed December 7. visit naturalsolutionsmag. Gazella present in-depth discussions of twenty speciﬁc cancers. 2009. price. Send out the “IMCJ Supplement Quality Audit Form.aspx.com/go/shop or call 800-841-2665 or visit your local bookseller. Weil could have a powerful influence as a unifier. Hlasney E. 1 • Feb/Mar 2010 17 . Go to: www. the 768-page Deﬁnitive Guide to Cancer encourages an integrative approach that embraces both alternative and conventional therapies in the battle against cancer. References 1. rather than using the more inclusive term integrative health care. drweil. with which I work.imjournal. Weil A. Accessible at: http://www. Accessed December 14.org/media/consumersurvey_ factsheet-2009. 2009. John Weeks.” Simply ask your affiliated vendors to fill in this straightforward. in his book. This can lead to the sense of exclusion articulated by the NDs and potentially felt by others who might read the book. Integrative Medicine and the Health of the Public: A Summary of the February 2009 Summit. Dietary supplements valued even in a challenging economy: annual consumer survey finds supplement usage remains steady. is the publisher-editor of The Integrator Blog News & Report.com Click on: “Resources & Content. and download your form today! NATURAL SOLUTIONS MAGAZINE’S LATEST BOOK.” Find out more information. 3.edu/ en/Reports/2009/Integrative-Medicine-HealthPublic. 2. 9.” then click “Quality Assurance. No.iom. Here’s hoping that Weil’s language will shift as the IOM’s did (see above). how to incorporate natural therapies. Are Your Clients Taking Tainted Supplements? How will you know? A movement is afoot. Naturopathic physician Lise Alschuler and medical journalist Karolyn A.com/drw/uART03076/A-Health-Care-Callto-Action-by-Andrew-Weil-MD. In return.
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