7
Concluding Comments

First, do no harm. Then do some good.

—Sir Cyril Chantler


The final panel of the summit, moderated by Dr. Harvey Fineberg, allowed moderators of the five previous panels, Drs. Michael Johns, Ermina Guarneri, Bruce McEwen, Elizabeth Goldblatt, and Sean Tunis, to reflect on what they had heard during their panels and throughout the summit. This panel also provided the moderators with an opportunity to comment on what they believed were the most important issues, priorities, strategies, and unanswered questions that challenge the advancement of integrative health care.

PANEL MODERATORS

Michael M. E. Johns, Emory University

Johns began his observations by noting how summit participants had clearly articulated the need for a more coherent vision and approach to health and health care that extends over a person’s lifetime. The care must pay attention to the body, the mind, and the soul and treat the individual as a full and equal partner in care decisions. Integrative health is not merely piling a series of new practitioner tools onto conventional medicine, but a whole new orientation toward person-centered care. He liked the notion that there would be an individualized plan for health over a life span. George Halvorson called this a toolkit that can integrate all health and care processes and that connects a person seamlessly with all the health care professionals.

Johns was struck by the discussion of an “optimizer” working on behalf of each individual. This could be an electronic health record or perhaps someday a telehealth application; it could be a person, serving in



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7 Concluding Comments First, do no harm. Then do some good. —Sir Cyril Chantler The final panel of the summit, moderated by Dr. Harvey Fineberg, allowed moderators of the five previous panels, Drs. Michael Johns, Er- mina Guarneri, Bruce McEwen, Elizabeth Goldblatt, and Sean Tunis, to reflect on what they had heard during their panels and throughout the summit. This panel also provided the moderators with an opportunity to comment on what they believed were the most important issues, priori- ties, strategies, and unanswered questions that challenge the advance- ment of integrative health care. PANEL MODERATORS Michael M. E. Johns, Emory University Johns began his observations by noting how summit participants had clearly articulated the need for a more coherent vision and approach to health and health care that extends over a person’s lifetime. The care must pay attention to the body, the mind, and the soul and treat the indi- vidual as a full and equal partner in care decisions. Integrative health is not merely piling a series of new practitioner tools onto conventional medicine, but a whole new orientation toward person-centered care. He liked the notion that there would be an individualized plan for health over a life span. George Halvorson called this a toolkit that can integrate all health and care processes and that connects a person seamlessly with all the health care professionals. Johns was struck by the discussion of an “optimizer” working on be- half of each individual. This could be an electronic health record or per- haps someday a telehealth application; it could be a person, serving in 155

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156 INTEGRATIVE MEDICINE AND THE HEALTH OF THE PUBLIC the role of health coach, agent, navigator, or partner; it could be a pri- mary care provider; or it even might be a medical specialist, depending on the time, the place, and the needs of the individual. The optimizer’s role would be to assure the right intervention at the right place at the right time by the right caregiver at the right value. Johns heard partici- pants talk about the need to localize care, in the home as often as possi- ble, and in the workplace—care should be centralized only when necessary. Integrative health care is about healthy living, wellness, and preven- tion, but also, when it is needed, the proper sickness care. Johns reiter- ated that all these dimensions of care should be based on evidence. However, he recognized that we have to revisit the question of what evi- dence is and how we determine that the evidence is sufficient to recom- mend an intervention, therapy, or approach. This requires reinventing the evidentiary model to better assess costs and benefits, said Johns. Based on the value that specific services or approaches provide to the individual and to society, new systems of incentives and rewards can be created. Last year, the World Health Organization reported on social and be- havioral factors in health. Most Americans seem to believe such a report applies only to the developing world, Johns said. However, social deter- minants of health touch the lives of every American, and communities across the country struggle with poverty, education, and employment. Unless we address these social factors, all of our other efforts will not improve the health of this nation, he said. Individuals and organizations are inevitably self-centered when it comes to their own interests, he said. This natural tendency may create significant interprofessional friction that could interfere with advancing not only integrative health care as a whole, but also the common goals that have been identified. Summit participants represented a broad mix of interests, people, backgrounds, and personalities, having notable passion, energy, and a great spirit. To ensure the success of integrative health and to overcome the potential for friction, Johns encouraged individuals and organizations to work together and harness the energy and spirit demon- strated at the summit. This may require some groups to become more selfless, and it will require all groups to embrace their unifying interests, he noted. Additional opportunities to come together may help the various professional groups to know and understand each other more deeply. Next steps, he said, are to circulate the summary of this summit widely and to agree on language and definitions. For example, he sug- gested replacing integrative medicine with integrative health. Another

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157 CONCLUDING COMMENTS needed step is to redefine value in health care to include not only clinical outcomes, but also patients’ perceptions of their health care and its re- sults. Finally, Johns said that stakeholders need to collaborate with pa- tients to find a clearer, more detailed path forward—perhaps the first step should be to agree on what health is. Erminia Guarneri, Scripps Center for Integrative Medicine Guarneri noted that when she went to medical school in the 1980s she kept firmly in mind Sir William Osler’s quote, “To alleviate suffer- ing, to heal the sick, and prevent disease, this is our work.” However, when her training was complete, she realized that, even for the most common and costly serious disease, her toolbox was primarily limited to a set of drugs. It did not contain anything that would have addressed the many issues covered at the summit. She was not trained in nutrition nor taught to understand that food is medicine. She was not taught that the mind can affect the physical body. What she was taught was to make a diagnosis, treat a disease, and see the next patient. Guarneri emphasized the importance of Carol Black’s inclusion of social factors in disease such as worklessness, poverty, and loneliness. The medical school curriculum typically focuses on diagnosis of dis- ease—asthma, obesity, hypertension, diabetes. However, children raised in homes where there are rats will have a higher rate of asthma; children raised in poverty or with physical abuse will have higher rates of obesity, diabetes, and poorer overall health outcomes. Doctors can give them in- halers for the asthma, diets to follow for the obesity, and insulin for the diabetes, but if no one addresses the rats, the poverty, and the abuse, she said, these medical interventions will not be effective. Recognizing the shortcomings in the traditional medical approach, about 13 years ago Guarneri and her team at Scripps embarked on an endeavor to prevent disease, heal people, and change lives through sci- ence and compassion. They found that a multidisciplinary team of health care providers is needed to address a disease’s underlying causes, such as maladaptive responses to stress and tension, poor nutrition, and sedentary lifestyle. Now, the country is on the threshold of changing the concept of primary care, she said, and it might even be expanded to include nurse practitioners, homeopaths, naturopaths, and others. To support such an expansion requires determining the right credentials for this field of prac- tice.

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158 INTEGRATIVE MEDICINE AND THE HEALTH OF THE PUBLIC Also to be considered are ways to incentivize health care providers and employers to keep people healthy in a variety of settings, said Guarneri. The health care system, schools, workplaces, day care centers, and nursing homes should have incentives to play their part. The science on preventing many of our most serious illnesses is available, but acting on this science requires collaborative, cross-sector efforts. Guarneri said that she and the Scripps Center for Integrative Medicine are committed to improving outcomes and well-being and preventing disease, but she commented that legislation will be needed to bring a more integrative, prevention-oriented health system to fruition. Bruce S. McEwen, Rockefeller University McEwen reviewed the promise and challenges in developing the sci- ence base for integrative health. He said that specialization and reduc- tionism in both medicine and science has caused the health system to lose track of the forest (whole-person health) by focusing on the trees (one body part or one system). The search for magic bullets to deal with complex, multicausation disorders has obscured the ability to appreciate, study, and manipulate the human organism as a whole, and recognize and deal effectively with the central role of the brain in regulating body systems. Yet science already has—or can develop—tools to understand how brain and body interact. Interestingly, investigating in-depth brain func- tion and brain–body interactions is key to understanding how even social environments affect the individual. Clinicians can work with the brain by altering attitudes and behavior and providing sympathetic and supportive environments, such as through the health coaches discussed at the sum- mit, said McEwen. The science panel acknowledged the need for greater understanding of the biological foundations of thought, belief, meaning, and purpose, including ways to foster self-efficacy and self-esteem. But, he noted, people with low self-esteem may be hard to reach with mes- sages about taking part in their own health. Integrative health care is built on the idea of personalization. Much in current and developing science will enable this individualized care. New and better technology will help scientists measure and understand outcomes in a range of promising fields—genetic polymorphisms, epige- netics, mediators related to stress and adaptation, proteomics, telomere research, and, of course, brain function. At the same time, McEwen

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159 CONCLUDING COMMENTS noted the need for sophisticated tools to make this information accessible and useful to health care practitioners and the public and for a better un- derstanding of what it takes to motivate people to change risky behavior. McEwen noted that basic scientists believe their research will sug- gest biological mechanisms that can lead to better therapies. However, they must realize that different disciplines, with different rules of evi- dence, will be involved in developing and implementing potential appli- cations of their findings. This suggests the need to foster sustained interactions and understanding across disciplines through more interdis- ciplinary training and systems-oriented research. Unfortunately, young scientists interested in pursuing interdisciplinary research often confront gaps in understanding between disciplines that reduce their chances for promotion and tenure, said McEwen, and few grant reviewers have the broad knowledge and perspective necessary to assess cross-disciplinary work. Interdisciplinary research also requires funding, noted McEwen. In the late 1990s, over the objections of many people at the National Insti- tutes of Health, Congress authorized creation of five mind–body centers. These centers have attracted highly creative researchers who are now working on the kinds of cross-disciplinary projects that can strengthen the scientific underpinnings of integrative health care. Vigorous outreach to both policy makers and the public would help build support for con- tinued funding of this type of research and greater application of research findings, concluded McEwen. Elizabeth A. Goldblatt, Academic Consortium for Complementary and Alternative Health Care To improve health and have a positive impact on lives, the social de- terminants of health, especially education, must be considered first, said Goldblatt. Education affects where people fit into society, their employ- ment, and their access to health care. The poor, the unemployed, and the homeless are not thinking about diet, meditation, or yoga. The education and workforce panelists started from the premise that the U.S. health system should shift from a disease-based to a wellness- based system that emphasizes patient-centered health care. To accom- plish this, students, faculty, and practitioners not only need education within their specific fields, but they all need to be steeped in patient- centered values and in wellness, health promotion, and compassionate

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160 INTEGRATIVE MEDICINE AND THE HEALTH OF THE PUBLIC care. For example, they need to be taught to begin treatment with less invasive, and usually less costly, interventions before moving to more invasive ones. Academic administrators and faculty should develop effective inter- professional education curricula and programs, she said. Students in all health disciplines could be brought together for required courses in well- ness and behavior change. In this way, trainees would begin to break out of their disciplinary silos. Goldblatt reiterated that if people are educated in silos, they will practice in silos, and that style of practice is increas- ingly untenable. Students should also be trained to include empathy, compassion, and caring in their service to their patients. There is a place for licensure in encouraging more multidisciplinary and interdisciplinary care teams. Licensure is valuable not only for doc- tors, nurses, and allied health care providers, but also for some comple- mentary and alternative medicine practitioners—terms that Goldblatt suggests may be outdated. In describing potential participants in a per- son’s health care team, it would be better to refer to them as licensed care providers without regard to discipline. Many of the other professional groups involved in self-care and wellness, such as yoga practitioners, meditation coaches, massage therapists, or exercise trainers, may not be required to have licenses, but many are subject to a credentialing process. Goldblatt suggested that other countries may offer insights on how best to assure the competency of such diverse team members. U.S. health care has available superb technology and a workforce of many dedicated clinicians. However, the nation has developed a culture driven by economics that does not always support good health. High rates of obesity, diabetes, hypertension, and depression suggest that Americans are not healthy in terms of mind, body, or spirit; furthermore, she said, many Americans have lost a sense of community and mutual responsibility. For low-income Americans, there is no effective safety net, and millions are left without basic insurance coverage—something available to people in every other developed nation in the world. The stress resulting from lack of insurance, access to care, and related social support further contributes to vulnerability to illnesses. Universal health care would, she said, greatly benefit our society, culture, and the health of all Americans.

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161 CONCLUDING COMMENTS Sean Tunis, Center for Medical Technology Policy The principal insights from the economics session, said Tunis, started with Senator Harkin’s presentation, which emphasized that the United States is faced with a once-in-a-generation opportunity for major political and social change. It seems as though the economic collapse may be leading to a collapse of a culture of greed, said Tunis. There may be a greater interest in values such as internal reflection, connectedness, and community support, and these renewed values are exactly what the integrative health community focuses on. The opportunity today, both politically and socially, for the kinds of reforms that summit participants believe in, could not possibly be better, he said. Tunis observed that the summit exposed a great deal of shared sym- pathy and belief in the value of integrative health care, but not much skepticism, which surprised him. He noted that not only was the level of sympathy high, but also that there was a willingness to be helpful in terms of moving things forward. There will be a lot of work to do, and this shared sympathy will be necessary to power the advancement of in- tegrative health. While there is clearly a great deal of evidence about the effectiveness of integrative health care and many of its component services, there is also clearly a lack of consensus about when this evidence is enough or good enough to support system reforms. In Britain, the King’s Fund has done some very useful work around the evidentiary requirements for in- tegrative health care, which may be helpful here. U.S. decision makers and policy makers will need to come to consensus on the appropriate scientific base needed. A big part of changing the U.S. health care system would be a move from the input-based or resource-based reimbursement system to an out- come-based system, said Tunis. Such a change would be advantageous to the kinds of services and programs summit participants are committed to. However, the details will be challenging, and decisions about who is re- warded for what contribution will have to be made carefully in order to reflect what is truly meaningful in terms of health care outcomes. Tunis’s last point reiterated something several panelists mentioned, which is the importance of resisting the temptation to place blame on other sectors. Otherwise, “We will never come to any sort of constructive resolution or forward motion,” said Tunis. Resisting pointing fingers is very consistent with integrative health’s philosophy of respecting the individual and honoring all perspectives, he said. Finally, he predicted

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162 INTEGRATIVE MEDICINE AND THE HEALTH OF THE PUBLIC that integrative medicine may turn out to be the most successful ap- proach to reforming the nation’s health system. Panel Discussion In a concluding session, participants were asked by Fineberg to iden- tify the most important thing they had learned throughout the course of the summit and the most important next step required to advance integra- tive medicine. A number of participants raised significant challenges and highlighted points from the summit presentations and discussions that were particularly salient to them. Some participants were gratified to find out how much evidence, from diverse fields, supports the concept of integrative health care. Addi- tional evidence that is needed could come from demonstration projects in a variety of settings, several participants said. The demonstration projects could involve examination of systems of care as well as mechanisms for health care delivery and reimbursement. Participants identified existing integrative approaches that may provide valuable information for estab- lishing demonstration projects; one participant highlighted a Department of Defense program that includes integrative providers, and another dis- cussed a capitated integrative medicine program offered by Blue Cross- Blue Shield of Illinois. Several participants endorsed the idea that integrative care models should offer a wide variety of services. However, some noted that current models should give greater attention to dental care and end-of-life care, especially since a preponderance of Medicare funds is spent in the last 6 months of life. This is, in part, a result of the find-it-and-fix-it mentality, which causes patients to hope that almost anything can be fixed and causes clinicians to keep trying different treatments because they view death as a failure, suggested one participant. Participants reiterated the need for developing and disseminating information explaining integrative care precepts to clinicians from all disciplines and to the public. One participant praised the approach used in IOM’s Crossing the Quality Chasm report, in which an equally complex issue was translated into six succinct points. The participant noted that an analogous list could help move integrative health care forward. From the perspective of one international participant, effective

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163 CONCLUDING COMMENTS promotion of the integrative health agenda and international collabora- tion on best approaches could help the United States learn what works in China, India, and many other nations and cultures. A number of participants expressed support for integrative health’s comprehensive, community-wide approach, and one suggested that part of what it should encompass is better control of environmental toxicities. Another suggested that efforts be made to integrate public health and environmental health at a global level. CLOSING REMARKS Ralph Snyderman, Duke University Harvey V. Fineberg, Institute of Medicine After two and a half days of informative presentations and lively dis- cussion, Dr. Ralph Snyderman, chair of the summit planning committee, and Fineberg, President of the Institute of Medicine, thanked all of the participants for their time, their active engagement, and their energy and enthusiasm throughout the summit. Snyderman and Fineberg said the event was far bigger and far more important than the organizers could have anticipated when they began the initiative more than a year earlier. Returning to the Rorschach blot that Fineberg discussed in his open- ing remarks, Snyderman reiterated that everyone had arrived at the meet- ing with some image of integrative medicine. However, those images were probably different in virtually every mind. Initially, he had hoped that the presentations and discussion could transform the Rorschach into the clarity of an Ansel Adams photograph that would give everyone a precise view of what integrative health care is. While the summit did not yield a unified interpretation, many in- sights were attained and models presented. After hearing from so many of the participants, Snyderman was certain that almost everyone could agree that at the center of the Rorschach is an individual with unique re- quirements for maintaining health, preventing disease, and health care services over their lifetime. Snyderman noted that the unique individual is each of us over the course of our lives; it is our friends and family members; and it is every one of the nation’s children, with their different socioeconomic backgrounds and opportunities, their different racial and ethnic identities, their different family dynamics, and their different futures.

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164 INTEGRATIVE MEDICINE AND THE HEALTH OF THE PUBLIC As different as those people may be from each other and as different as their needs may be, health and well-being is a central resource to every one of them. At its root, health is about enabling people to live more fulfilling and meaningful lives. As Fineberg said, “What we are seeking most deeply in health and health care is really the same as what we are seeking in our lives.” This individual-centered approach takes into account the many com- ponents that touch lives and affect health, Snyderman noted. People are surrounded by family, friends, and larger social groups who can influ- ence them, positively and negatively; they are exposed to various envi- ronmental factors that can help or hurt them; and with integrative health care, they can interact with a health system that can, over time, work with them to sustain health and well-being and minimize disease. Most important, if they are fortunate, they will find purpose in life and the things that are meaningful to them, to sustain them and nurture their spirit, suggested Fineberg. “For some, that feeling may arise from some- thing as simple yet as deeply meaningful as witnessing a granddaughter’s first communion, or participating in any of life’s other profound mo- ments of transition and meaning.” Snyderman observed that in the blend of discussions, there emerged a great deal of understanding, shared ideas, and inspiring hopes. He said, “The diversity of our thinking around that Rorschach, with the individual at the center and care envisioned over a lifetime, will bring us to impor- tant places. I do not know where the ideas and discussions started here will go next, but it is very important that they have started and that we all remain committed to seeing them incorporated into rational health care reform.” Snyderman noted that Fineberg was wise to ask people, near the end of the plenary session, what they had learned, what for them was differ- ent. He concluded by saying that “To some degree, all of our minds have been changed, unalterably. We are different people, capable of taking different actions. Much of what comes out of the summit will depend on the spontaneous actions and the creativity of every person in the audi- ence. We all can play a role in keeping this movement going forward.”