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 Do Graduates of the U Arizona Fellowship Establish Integrative Medicine Practices? Survey Findings from Richard Schneider, MD 
The following is one in an ongoing series of columns entitled Integrator Blog by . View all columns in series
Summary: Duke Primary Care physician Richard Schneider, MD, a recent graduate of the Fellowship in Integrative Medicine at the University of Arizona Center for Integrative Medicine, found difficulties in developing an integrative medicine practice after he completed his program. He wondered if other graduates did. Schneider surveyed them. Just 23% were in integrative practices. His overall conclusion: "The results are quite encouraging, but not without caveats to the development of an IM practice." Here are Schneider's findings, plus a look at perceived barriers and areas for work to facilitate change.

Graduates of IM Fellowship surveyed on success in establishing practices
The signature educational program for integrative medical doctors, particularly those linked to academic medicine, is the Fellowship in Integrative Medicine at the University of Arizona Center for Integrative Medicine. Over 500 MDs and DOs have completed the 1000 hour, 2-year course of study. Their success in setting up practice as integrative medical doctors is one useful measure of the uptake of integrative medicine in the delivery system.

So how are these U Arizona Fellows in Integrative Medicine doing? What challenges are they facing?

Richard Schneider, MD is a recent Fellow.
After finding "some difficulties" in establishing an integrative medicine practice, Schneider wanted to learn if others were too. He informally surveyed 27 of his fellow graduates. Below is his report.

Schneider presently serves as medical director for Duke Primary Care's Creedmoor Road Clinic. He
is also co-founder and faculty at CoHvation, which he describes as "a think-tank for collaborative healthcare innovations which seeks to assist and promote Integrative Medicine practice in both the in and out patient setting."

Integrative Medicine: The Spirit is Willing

Richard, Schneider, MD

Schneider: How are the other Fellows faring?
The concept of Integrative Medicine has taken its proper place in the health care paradigm over the past few years. Unfortunately, although the spirit of the IM provider is strong, so are the challenges in developing a practice prioritized to the practice of Integrative Medicine.

As a recent graduate of the Fellowship in Integrative Medicine from the University of Arizona, I too had the strong desire to practice what I had come to develop a passion for: Primary Care Integrative Medicine. My training was state of the art from mentors with a strong presence in IM.

 "Even working for a well respected
academic medical centers which has
invested significantly in Integrative Medicine,
I have not been able to advance my
integrative medicine practice
to the degree I would like."

Unfortunately, developing a practice has been somewhat challenging. Even working (as a Medical Director for one of their Internal Medicine practices) for a well respected and arguably one of the top 10 academic medical centers which has invested significantly in Integrative Medicine, I have not been able to advance my integrative medicine practice to the degree I would like.

Wondering whether I shared the difficulties in developing an IM practice with others, I decided to run an informal survey of 27 recent graduates of one of the premier Fellowship programs in IM both nationally and internationally. The results are quite encouraging, but not without caveats to the development of an IM practice.

For example, while over 90% want to practice integrative medicine either exclusively or at least most of the time, only:

  • 23% are currently in an IM practice.
For those asked if they are ready to develop an Integrative Medicine practice:
  • 50% are in the planning stages or actively pursuing it, and another
  • 23% are thinking about it.
When it comes to some of the barriers limiting a provider's practice of integrative medicine, most indicated:
    • reimbursement problems.
Next most identified was:
    • time constraints.
This was followed by:
    • current practice limitations
    • legal concerns regarding themselves (one indicated that the FDA does not approve integrative medicine treatment) and their
    • referral sources as well as
    • peer acceptance.

edical insurance coverage was mentioned as a problem. Coding has been an issue with respect to reimbursement. Most find themselves using traditional ICD-9 codes for [these typically treated conditions]:

  • cardiovascular disease,
  • hypertension,
  • musculoskeletal disorders,
  • chronic fatigue,
  • chronic pain,
  • diabetes,
  • dyslipidemia and
  • menopausal symptoms.

When asked to rate the importance of certain areas to the development of an IM practice, most again indicated reimbursement.
Then came:

  • practice development,
  • quality referral sources,
  • political advocacy and
  • seminars to enhance networking among providers.

One responder summed it up quite succinctly: "It's great to be altruistic, but it's a realty that we've got to pay our bills to keep our doors open."

 "A willing spirit has taken us far -
   blood, sweat, tears and advocacy    
might take us home."

Working within the outpatient integrative medicine community, as well as on a committee recently bringing IM to the inpatient setting, I quickly came to the realization that while there are a number of quality programs teaching the fundamentals of IM, there was no one entity focused primarily on the development and promotion of outpatient or inpatient integrative medicine practices.

As practitioners and believers in the value of integrative medicine we have vested much on this journey.

Now it's time to recognize the reality of healthcare delivery, the impact of reform and the place that integrative medicine takes in that calculus.

A willing spirit has taken us far - blood, sweat, tears and advocacy might take us home.

Richard J. Schneider, MD
Medical Director
Duke Primary Care Creedmoor Rd.
Raleigh, North Carolina


: Questions: What sort of integrative medicine are the 23% (6 of 27, presumably) practicing? In what environments are they practicing? Integrating what modalities or professionals? What stories might be told by the roughly 50% (13/14 of 27) who are actively pursuing establishing integrative practices but haven't yet been successful? And how about that other quarter, the fallow Fellows, who paid their money, spent their time, but are not even thinking seriously about employing their new skills? And how about those who have been out longer? How are they doing?

 I wonder if perhaps the sweet spot
Schneider identified for practice building 
is the relationship factor.

I am reminded of the survey data on practices of licensed acupuncturists. Do 47% of these LAcs truly prefer to work part-time? Here, some 75% of the Fellows are not yet making a living based on what they paid good money to learn. We have a problem of under-employment in both fields.

Noticeably, the challenges Schneider found that rank highest as barriers are those most tethering of coordinates: time and money, known here as "reimbursement" and "time constraints." Tough to budge. Sobering.

I wonder if perhaps the sweet spot
for building a practice identified by Schneider is the relationship factor, known here as "referral sources." Are the spirits of these new integrative medicine fellows willing to relentlessly work to earn the hearts and minds of their health system colleagues? Are the Fellows equipped to persevere in building communities of support for the principles and practices for which they are emissaries? Focusing on this human-to-human work may produce the most significant rewards;  including, potentially, opening new relationships to both time and money.

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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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