Does the Integrative Medicine Field Care about Whole Systems Research? Results from a Special Issue

Does the Integrative Medicine Field Care about Whole Systems Research? Results from a Special Issue

When a global scientific community for traditional, complementary and integrative medicine emerged 20-years ago, it declared for the importance of what it called “whole systems research” (WSR). Such exploration was declared as core mission of an organization, ISCMR, formed to network the community. It was formed in contra-distinction to reductive, single agent trials that were then a relatively unchallenged “gold standard” for research. Researchers associated with chiropractic, naturopathy, acupuncture and other licensed integrative practice fields prioritized such research in a 2009-2011 campaign to influence the priorities at what is now the NIH National Center for Complementary and Integrative Health. Academic integrative medical doctor researchers called for it. Yet now a special issue of an integrative health journal – available entirely in open access to the public – is questioning whether steam is left in that thrust – and whether, ironically, such interest is dissipating at a moment of potentially broader embrace.

The journal issue at stake is one with which I have been involved, together with a 11 others associated with the WSR movement. Some, like Cheryl Ritenbaugh, PhD and Heather Boon, BScPhm, PhD, date back to the WSR movement’s beginnings.  In an introductory editorial, the 3 of us explain how, backed by a philanthropist with historic investment in WSR, we began exploring development of a special issue of JACM-Paradigm, Practice and Policy Advancing Integrative Health (The Journal of Alternative and Complementary Medicine).

Following consultation with team members, we shaped the call for papers around two noted trends. The limited uptake of the “whole systems research” (WSR) concept in either integrative or conventional medicine meant we would be unlikely to draw much of we merely fished for WSR clinical trials. At the same time we noted the seeming paradox of emerging alignment of early WSR concerns with the movement for value-based medicine.

 

With this in mind, we chose to frame our call for papers more broadly. The title we eventually used of the just-published issue: Multimodal Approaches in Integrative Health: Whole Person, Whole Practices, Whole Systems. (The whole issue is in open access thanks to the philanthropic partner.)

The submissions were doubly surprising.

First, we chose to invest in what would be the first broad review of WSR that the field has seen. To create a bridge to the present, and explore the early work, we invested some of the philanthropic support to fund University of Toronto researcher and Boon protege Nadine Ijaz, PhD to lead a team that examined 41 WSR exemplars in a study entitled Whole Systems Research Methods in Health Care: A Scoping Review. The Ijaz-led analysis includes examinations of whole person approaches from multiple traditions – from research from Ornish on cardiovascular issues and Bredesen on cerebrovascular problems to studies of naturopathic, Ayurvedic, yoga therapy, traditional Chinese medicine, and midwifery approaches. Ijaz neatly arranges these from multiple perspectives, including, to name a few:

  • The various types of conceptual models
  • Types and levels of research controls used
  • Types of individualization strategies allowed
  • Types of diagnosis used
  • Primary features of the WSR interventions
  • Outcomes assessment strategies

A leading conclusion: “Aligned with trends emphasizing ‘fit-for-purpose’ research designs to study the ‘real-world’ effectiveness of complex, personalized clinical interventions, WSR has emerged as a maturing scholarly discipline.”

Yet despite the apparent maturation, the call for papers netted few new WSR exemplars. Only four were selected for the issue. The most intriguing was a teaser of a preliminary oncology study from an Ottawa Integrative Cancer Center team led by Dugald Seely, ND that shared the process involving as multidisciplinary team for creating a protocol for researching naturopathic peri-operative treatment of individuals undergoing surgery for lung, gastric, and esophageal cancer. Only one study based substantially in early WSR theory was submitted, from Ayurvedic medicine researcher and practitioner Jennifer Rioux, PhD with a focus on treating individuals with obesity’ via a dual-diagnostic lens.

The power of the special issue was an unanticipated consequence of casting a broad net. We discovered that many academic integrative medicine researchers in the United States are riding a wave of institutional interest in shifting chronic pain treatment to include more pharmacologic approaches. These institutional challenges make them change agents to transform whole systems of care toward a new paradigm, a new model. Their typically qualitative studies offer roadmaps for the needed transformations.

Transformation of Whole Systems of Delivery

The special issue was thus indirectly shaped by the US opioid crisis. A half-0dozen paper focus on development of whole person-oriented integrative pain programs to transition whole systems of care in multiple organizations and clinical contexts. These include: University of California San Francisco (primary care safety net clinic), Oregon Medicaid (federally qualified health centers), University of Vanderbilt (outpatient academic medicine chronic pain), and one from University of North Carolina, Chapel Hill (pediatric hospital). (In addition, a Harvard Medical School team explored cost-effectiveness of a multimodal model for back pain (outpatient academic medicine).

The twin jewels in this set papers were from researchers examining efforts to convert the Veterans Administration to a “whole health model” and include more complementary and integrative approaches throughout the VA in order to do so. The first, led by Greater Los Angeles VA researcher Stephanie Taylor, PhD, is entitled “What Should Health Care Systems Consider When Implementing Complementary and Integrative Health: Lessons from Veterans Health Administration.” The researchers used semi-structured, in-person qualitative interviews with 149 key stakeholders at 8 VA medical centers to clarify 9 key factors that facilitated implementation and 7 challenge areas.

That in-the-weeds work is offset by an invited commentary from two leaders of the VA’s Office of Patient-Centered Care and Cultural Transformation, Tracy Gaudet, MD and Ben Kligler, MD. In “Whole Health in the Whole System of the Veterans Administration: How Will We Know We Have Reached This Future State?”, Gaudet and Kligler describe the VA’s “whole health” model emerging in the VA’s 18 regions. Success in this transformation is the VA’s “future state.”

For researchers, measuring success in achieving the VA’s “whole health” goals means asking new questions: “If we are seeking new health-focused outcomes, we need to rethink what we measure.” Questions suggested by Gaudet and Kligler include:

  • Are the VA’s divisions working on other determinants—homelessness or social isolation, for instance—coordinating better with those providing the same veteran’s clinical services?
  • How do we accurately assess the impact of the work of our whole health peers and coaches?
  • How [do we] measure purpose and meaning in our clinical staff as they experience more of the whole health approach in their own lives?

The journal began by breaking down prior barriers to what could be included in a special issue that includes a WSR brand. Yet while the field may be lying relatively fallow, the Special Issue offers strong signs that renewed investment in clarifying and strengthening WSR methods may have significant returns. Gaudet and Kligler put it this way:

“In the broader context of the call of [Donald] Berwick and others toward a multiyear march of the medical industry to become a true health care system, it is possible that the whole system research conversation of 20 years ago was the right conversation, ahead of its time. Perhaps that conversation’s time of latency is over. What is certain is that we need to be putting new thinking and new research resources behind new kinds of questions if we are to effectively assess the outcomes of this new/old approach to health.”

Tracy Gaudet, MD and Ben Kligler, MD, MPH
Office of Patient Centered Care and Cultural Transformation, Veterans Health Administration