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 My Meeting with the U.S. Leader for Complementary and Alternative Medicine Research  
 
The following is one in an ongoing series of columns entitled Integrator Blog by . View all columns in series
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.

Richard Nahin, PhD, MPH - sat in on the meetingWhole 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 johnweeks@theintegratorblog.com
for inclusion in a future Your Comments Forum.
      
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 About The Author
Resumes are useful in employment decisions. I provide this background so that you may understand what informs the work which you may employ in your own. I have been involved as an organizer-writer in the emerging fields......moreJohn Weeks
 
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