Historic summit on integrative medicine.
|Article Type:||Conference news|
Health maintenance organizations
(Conferences, meetings and seminars)
Integrative medicine (Health aspects)
Integrative medicine (Conferences, meetings and seminars)
Physicians (Conferences, meetings and seminars)
|Publication:||Name: Townsend Letter Publisher: The Townsend Letter Group Audience: General; Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2009 The Townsend Letter Group ISSN: 1940-5464|
|Issue:||Date: Oct, 2009 Source Issue: 315|
|Product:||Product Code: 8000130 Health Maintenance Organizations; 8011000 Physicians & Surgeons NAICS Code: 621491 HMO Medical Centers; 621111 Offices of Physicians (except Mental Health Specialists) SIC Code: 6324 Hospital and medical service plans|
|Geographic:||Geographic Scope: United States Geographic Code: 1USA United States|
The Institute of Medicine sponsored a "Summit on Integrative Medicine and the Public" February 25-27, 2009. A prestigious body of speakers and attendees created a dynamic conference in which the content and discussions provided vital information for transforming the US health-care system. Topics included patient-centered care, the scientific basis of integrative medicine, health-care financing reform and value-driven care, and mind-body relationships and health.
The Institute of Medicine (IOM) is considered America's preeminent body of physicians, scientists, and academicians interested in health and medical issues. It is a part of the National Academies, which also includes the National Academy of Sciences. The IOM produces independent recommendations and policy reports by enlisting various experts to address the scientific and technical aspects of some of society's health problems.
From February 25 to 27, 2009, the IOM convened a "Summit on Integrative Medicine and the Health of the Public" at its headquarters in Washington, DC. Approximately 600 people participated in this historic meeting, which included a wide variety of experts in integrative medicine as well as people in leading positions in government, industry, and academia. This summit was cosponsored by the Bravewell Collaboration, a foundation composed of leading philanthropists dedicated to transforming the culture and delivery of health care.
The summit content and discussions provided vital information for transforming the US health-care system. Topics included patient-centered care, the scientific basis of integrative medicine, health-care financing reform and value-driven care, and mind-body relationships and health. Prior to the conference, the IOM commissioned several papers to provide background information on integrative medicine's performance in prevention and wellness, patient-centered care, research, public education, professional education, and economics and policy.
The speakers included many of the movement's high-profile leaders, including Dean Ornish, Mehmet Oz, and Kenneth Pelletier. Evidence of the interest in the broad field of integrative medicine was the inclusion of Thomas Donahue (CEO of the US Chamber of Commerce), George Halvoson (chairman and CEO, Kaiser Foundation Health Plan), Senator Tom Harkin (D-IA), Bill Novelli (CEO, AARP), and Reed Tuckson (chief of medical affairs, United Health Group, a major HMO, and former senior vice president of the AMA). Other speakers included Mimi Guarneri, (cardiologist and medical director of the Scripps Center for Integrative Medicine), David Katz (internist and founder of Yale's Prevention Research Center), Victor Sierpina (University of Texas), Victoria Maizes (University of Arizona), Tracy Gaudet (Duke University), and Josephine Briggs (director, NIH National Center for Complementary and Alternative Medicine). The chairman of the planning committee for the conference was the eminent Ralph Snyderman, chancellor emeritus, Duke University.
Perhaps most impressive of all was the audience itself, who consisted of many health and medical experts who often keynote at health conferences, including Jeffrey Bland, Jon Kabat-Zinn, Larry Dossey, Woodson Merrill, and Wayne Jonas, as well as dozens of professors from leading medical, naturopathic, nursing, acupuncture, and chiropractic schools.
Harvey Fineberg, MD, PhD, president of the IOM, welcomed attendees and acknowledged that integrative medicine is a bit like a Rorschach blot test because its meaning seems so varied.
Snyderman gave the opening address, expressing concern about the state of medicine today. He asserted: "No other industry holds its customers in such high disregard, except perhaps the airline industry." He described health care today as uncoordinated, disease-oriented, reactive, physician-directed, not personalized or safe, and extremely expensive. Snyderman expressed his strong appreciation for modern medical science, but he humbly acknowledged that most drugs and technologies have not been proven efficacious* and that at best it may only affect about 25% of contemporary health concerns.
Tuckson, who represents one of the large HMOs, warned attendees that we all may want health-care reform, but whatever changes we want must have evidence of benefit. He urged scientific inquiry as well as evaluation of demonstration projects. He also noted, however, that "the enemy of the good is the perfect," and we cannot wait until all the evidence is in or for wide consensus before beginning to make serious changes. Tuckson reminded the audience that nearly all patients want every treatment that they receive to be covered by insurance, yet third-party payers will always insist upon seeing "evidence" of benefit before allowing coverage. This requirement is not only reasonable but necessary; yet later discussion noted the great number of conventional medical interventions that are both very expensive and do not have adequate evidence of benefit.
Pelletier echoed a similar viewpoint, asserting, "Trust in God, but everyone else must present data." He noted that we may not necessarily need new monies in health care but just better allocation of present resources. Because so many current high-tech methods have not yet been proven efficacious, there are great savings to be obtained by no longer reimbursing questionably effective (and expensive) health interventions.
Pelletier has consulted to many major American corporations that have developed various disease-prevention and health-promotion programs for their employees. He noted that 62 of 63 studies of cost-effectiveness, cost benefit, and return on investment have shown positive results. According to his review of this research, a return on investment for health programs usually takes only 3.25 years. Further, evidence-based return on investment ranges from $3.50 to $4.90 for every $1.00 invested.
Bill George, a professor of business management at Harvard Business School, was the CEO, president, and chairman of the board at Medtronic Inc., the largest medical technology company in the world that began by creating heart pacemakers. His wife, Penny George, was past president of the Bravewell Collaboration, cosponsor of this summit; and the George Family Foundation has been a leading supporter of many Bravewell efforts. (Yes, there does seem to be a bit of social and spiritual justice that profits from high-tech medical endeavors are being used to support various high-touch health strategies.) Bill George spoke about his personal experience at Medtronic, insisting that it is important for employers to reward healthful behaviors rather than punish bad ones. He said that his company gave employees $50 per month ($600 per year) for complying with some healthful behaviors, and noted that a gym is not a perk in an office but a necessary component.
The Most Powerful Speech
Dean Ornish made what many attendees considered to be the most powerful presentation of the summit. He described his and many others' research that showed significant changes in the health status of people suffering from many of the leading causes of mortality in the US. Ornish's own research has shown that significant changes in dietary and exercise were substantially effective in improving health status in people suffering from cardiovascular disease and prostate cancer. Further, he said that the minor dietary and exercise recommendations of the American Heart Association and the National Cancer Society are simply inadequate to create significant positive results, thereby leading to poor compliance due to the small health improvements.
Ornish's wisdom and experience here seems in sync with President Obama's desire to make significant changes in various orthodox institutions in order to create real solutions that work. With America's present health statistics rank us 37th (!) in the world, suggesting that doing more of the same or making minor changes in health reform will not provide the real improvements that Americans want and need today.
Ornish also referred to a study in which curcumin (an active ingredient in the spice turmeric) was found to have 2000% increase in bioavailability, and therefore significantly greater health benefits, when combined with a type of pepper used in curries. Ornish sought to warn attendees to avoid looking at studies that test simply one ingredient. Many recent studies, for instance, have found few or no results from using vitamin C or E, when in fact most nutrition-oriented physicians and practitioners do not limit themselves to such single-ingredient treatments.
Ornish also discussed several body-mind treatment programs, including certain meditative, visualization, and yoga practices, to improve health status and quality of life for people suffering from a host of serious ailments. He also noted their importance for soldiers as they return from combat operations, usually suffering from posttraumatic stress disorder.
Many speakers referred to the challenge in health care today in which physicians and other primary-care clinicians do not have the time or expertise to be their patients' "health coaches." There seems to be a real need for a person on the health-care team who works personally with the patient to help enact health-enriching behavioral changes. Some attendees thought that psychologists might fill this role, others thought nurses may be best, and others wondered if a new type of health professional is needed.
Further, Ornish reported on research on telomeres, a gene associated with long life. His research published in Lancet Oncology (November 2008) discovered that significant dietary changes had direct effects on telomeres, thereby verifying that our genetic heritage can be influenced and changed. While our genes may indeed have powerful effects upon our health and life, such influences are not permanent but can be transformed.
Ornish's expansive message also raised the provocative notion that a vegetarian diet is not only healthier for people but also for our planet. He noted that livestock production leads to more global warming effects than all transportation sources combined.
A View to and from the Hill
Two days before the conference began, the Senate Subcommittee on Health, Education, Labor, and Pensions held a hearing on integrative medicine. Chaired by Senator Barbara Mikulski (D-MD), the subcommittee heard testimony from Wayne Jonas; James Gordon; Sr. Charlotte Kerr; Mary Jo Kreitzer; and Cathy Baase, corporate medical director for Dow Chemical Company. Then, in the middle of the summit, Harkin held another hearing on integrative medicine with what some of us referred to as the "integrative health dream team," including Ornish, Andrew Weil, Mehmet Oz, and Mark Hyman.
The third day of the summit began with a rousing presentation from Harkin. He reported on these Senate hearings, noting that just that week President Obama had asserted that health reform was a major priority for him and for the American people, and that prevention and wellness programs have to have an important place in this health reform. Obama has also designated over $1 billion for outcomes evaluation of health and medical treatment programs, to determine what really works.
Harkin asserted: "American always do the right thing ... after they have tried everything else." Indeed. Harkin has been a long-term advocate for integrative health (although he originally expressed interest and support for "integrative medicine," an attendee suggested to him what others at this summit had previously expressed: "integrative health" is more comprehensive a term than "integrative medicine"; within the remaining time of the Q&A session with Harkin, he referred to integrative health). Harkin was the primary sponsor of the creation of the Office of Alternative Medicine, as well as the National Center for Complementary and Alternative Medicine.
Harkin noted that the status quo (which he also called the "stagnant quo") has reimbursement and incentive priorities in the wrong place. He promised to make certain that these priorities be changed.
In 1993, I consulted to the World Health Organization at a special conference it sponsored that sought to inquire what it should and would be doing in the year 2020. Whenever one attempts to predict the future, it is important, perhaps necessary, to include some heretics, because what may be unconventional or even heretical today may be an integral part of the future. What is equally true about the future is that what is conventional today is tomorrow's quackery. These observations are not actually predictions; they are statements of the evolution of social history.
At this WHO meeting, Fineberg, at the time dean of Harvard School of Public Health, was a fellow consultant. He was one of a select few who reached out to me to learn more about homeopathy. We shared a private lunch, and his inquiring mind gave me a certain confidence that our paths again would cross. Indeed, they have.
The very concept of "integrative health" is quite comprehensive, and yet, with respect to getting the biggest bang for the buck, we must honor the Hippocratic tradition that asserts "First, do no harm." How this translates into health improvements is that we should explore and exhaust safer methods first before resorting to the big (and expensive) guns of medicine and medical technology. Also, there is general recognition that we need to move our thinking about health care from where the physician is at the center to where the person is at the center.
Several speakers at this summit discussed the need and the demand for "data." During audience participation moments, I voiced my concurrence -but also a warning. In homeopathic and naturopathic thought and practice, there is a profound respect for the "wisdom of the body." If we set up clinical trials that simply evaluate whether a treatment is effective in eliminating a symptom, we may find that this treatment is effective only in suppressing the symptom and sometimes creating a more serious chronic ailment, rather than enacting a true cure.
We therefore need to have clinical trials, but they must not only evaluate specific symptoms but also overall health status. They must not ignore side effects, because such new symptoms are not side effects at all; they are usually the direct result of a drug's toxicity or its ability to suppress the disease to deeper and more serious levels.
Further, when we seek "evidence," we should evaluate evidence not only obtained from randomized double-blind trials, but also from outcome studies, cost-effectiveness studies, and, when possible and appropriate, basic science trials.
We need to remember that we today accept most surgical practices even though the vast majority of them have not been proven effective based on double-blind, placebo-controlled trials. Few people consider surgery "unscientific'' just because it is not viable to conduct placebo-controlled trials. Yet many physicians, scientists, and health-policy analysts assume that some alternative treatment methods are unscientific because they too cannot be evaluated in placebo-controlled trials (how does one give a placebo meditation or a placebo yoga posture?).
Likewise, many treatments used by "integrative practitioners" comprise a "package" that includes various dietary changes, vitamin and mineral supplements, herbal remedies, homeopathic medicines, yoga practice, stress management methods, and so on. Evaluations of the outcomes of such packages of treatment are truly necessary.
At the summit, I referred to two cost-effectiveness studies conducted by the French government. In 1991, the totality of costs associated with homeopathic care per physician was approximately one-half that of the totality of care provided by conventional primary-care physicians. However, although homeopathic physicians, on average, saw significantly fewer patients due to the more labor-intensive tendency of homeopathic care, their overall cost per patient was still a significant 15% less. It is also interesting to note that these savings appear to increase the longer a physician has been using homeopathy. A follow-up study in 1996 confirmed these results.
This survey also noted that the number of paid sick leave days taken by patients under the care of conventional physicians (general practitioners) was 3.5 times higher than that by patients under the care of homeopathic physicians. These figures suggest further benefit and savings from the homeopathic approach to care.
At this summit, there were several professors of genetics and other basic sciences who discussed the most recent scientific discoveries in their fields. However, I was a bit surprised at the casual reference to "genetic causes" of illness and to new (and old) infective agents that "cause" this or that disease. My concern here is that because language is so important, we must draw from systems biology and systems thinking to realize that it is more accurate to say that these influences are "cofactors" for diseases, not causes of them. The concept of causality tends to be linear, when in fact cause is rarely so simple. The susceptibility of the host always influences whether an infective agent leads to disease or not, and, as Ornish and others have now noted, even genetic status of an individual can be altered.
Finally, we must be humbler in how we all use the words and concepts of "scientific medicine." An IOM special report, "Informing the Future: Critical Issues in Health" (published in 2007), noted that 1/3 of Americans today take five or more medications. Yet even if all of these drugs have been proven "scientifically" to work, each drug was tested individually, not in combination with one or two, let alone five, other drugs. Further, most of the studies have not been conducted on children or the elderly, yet the high quantities of drugs are prescribed for them. Still more disconcerting is that most medication is tested for very short periods of time, even though many drugs are used over years or decades. I certainly realize that such evaluations are complex and difficult, but these issues simply mean that we must remain humble in our sense of which drugs work, when, and for whom.
To see agenda and presentation slides of the IOM Summit, to watch the webcast, and to access the commissioned papers that were available prior to the summit, go to: http://www.iom.edu/?ID = 52555.
The US Senate hearing on integrative medicine by the Committee on Health, Education, Labor, & Pensions in which testimony was provided by Drs. Andrew Weil, Mehmet Oz, Dean Ornish, and Mark Hyman can be watched at: http://help.senate.gov/Hearings/2009_02_26/2009_02_26.html.
by Dana Ullman, MPH
Dana Ullman, MPH, is a leading advocate for homeopathic medicine. He has authored 10 books in the field, including his best-selling Everybody's Guide to Homeopathic Medicines and his newest book, The Homeopathic Revolution: Why Famous People and Cultural Heroes Choose Homeopathy. His e-book is the most up-to-date source of information on clinical research in homeopathy (Homeopathic Family Medicine: Evidence Based Homeopathy-available at www.homeopathic.com).
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