In 2001, Mayo Clinic received a transformative jolt of integrative energy at a fortuitous moment. The institution was about to celebrate the opening of the 21-story Gonda Building. What a Minnesota news account called a “transformative project” was funded originally with a $45-million bequest from Southern Californians Leslie and Susan Gonda. Their daughter, Lucy Gonda, then an activist and philanthropist in the emerging integrative medicine field, recognized an opportunity. There would likely be no better time to stretch herself for her most significant integrative grant. She piggy-backed onto the celebration of her parents’ gift to throw in the spotlight a struggling, nearly invisible integrative medicine operation. This article examines what has been built since the injection from the “god-mother of integrative medicine at Mayo.”
There is an inside line on this story. At the time, I was in the lovely role – for one typically struggling to raise money for integrative projects – of working the other side. I was helping Gonda, a current Integrator philanthropic partner, with her portfolio. Lucy Gonda brilliantly realized that Mayo’s moment of celebration could also be a rare chance that a gift that was small for the institution, yet a major stretch for her, would train the attention of Mayo’s leadership on the nascent integrative team. She chose to make a gift of $250,000 – five times the size of any other one-time support she made when she was working as a philanthropist. Time has shown that her gift did what she wanted in opening integrative care options for tens of thousands of patients at Mayo and countless more who follow the Mayo model.
God-mothering integrative patient care
When I reached Mayo’s then director of integrative medicine and now its research director, Brent Bauer, MD, I asked him to recall the impact:
Lucy? Lucy is the godmother of integrative medicine at Mayo. Hers was our first gift specifically targeting integrative medicine. It had the Gonda name on it, so it caused everyone to perk up and take notice. Lucy’s visibility, and that family name – it probably opened doors at Mayo that would have taken another decade without her leadership – if ever. It really put us on the map and got us going.
For the three of us closely involved in planning the use, there was yet another story within this story, that was quite challenging. Like most philanthropists, Gonda was motivated in her philanthropic work by the importance in her own life of therapies from outside conventional medicine. She wanted to see her $250,000 go directly to benefit patients. She wanted such therapies in patients’ hands, at Mayo, and she wanted them there yesterday. Investing in research was too slow.
What Gonda wanted wasn’t, as Bauer was acutely aware, allowable under the “Mayo model”. I asked Bauer to describe how the model works:
We start with what patients are seeking – this idea of listening to the practice. We can use external data to make our decisions, but in a large academic medical organization, we need do it our own way, with our own research. We ask the questions ‘does it work?’ and ‘does it fit the Mayo model of care?’. I am always surprised by how many say, if Mayo does it, we can do it.
For a time, the three of us were entangled in a process that pitted the short-game of quick delivery of a few services against the long-game of investment in Mayo’s research-focused vetting process. The latter, as Bauer knew, was the only way to embed the services at Mayo. It was also the cultivation needed to yield this known multiplier effect in other institutions.
Eventually Bauer got his research and Gonda the vast expanse of services for patients. The chart above provides 7 years of data on growth of such clinical services at Bauer’s clinical base in Mayo Rochester. Bauer says that in most categories, while growth has leveled off some, it has continued over the last 7 years since the chart was developed.
And these data are just from the Mayo, Rochester, facility. In fact, Bauer shares that “Gonda’s vision for reaching more patients” has now taken root in two additional Mayo outposts since the data above were aggregated. Mayo created “sister integrative medicine programs” at Mayo Clinic Arizona and at Mayo Clinic Florida. The latter has attracted as its leader one of the pioneers in hospital based integrative services, Adam Perlman, MD, MPH. Perlman’s prior career has included a significant term as director of integrative medicine at Duke and in a volunteer capacity as chair of the Academic Consortium for Integrative Medicine and Health (The Consortium).
Bauer shares that “each is run independently but all three site leaders meet on a regular basis to share best strategies around practice, research and education.” He adds that “by sharing successes and failures, best practices are promulgated across the entire enterprise, reaching an ever increasing number of patients and staff.”
Applying the Mayo model
One example of the application of the Mayo model is massage. Bauer shares that Mayo’s cardiovascular surgeons were interested in reducing pain after surgery: “We did two small studies on massage, a pilot then a second larger trial. The positive outcomes led the cardiovascular surgery practice to hire a massage therapist.” He adds that Mayo has since switched massage for their patients from being funded by cardiovascular surgery to “a small fee-for-service model” that makes massage available to any patient. The interest in massage continues. A day before the interview, Bauer sent a recent publication with positive outcomes from a pilot on use of massage in the hospice arena.
The research output, given the model, is significant. A 2019 Integrative Medicine Program Report points to roughly 20 studies recently published. Bauer also shared what amounted to a small pamphlet of research projects presently under review, being written, in process, and under concept development. I asked him if there is any therapy he recalls that didn’t make the grade, following research.
We’re pretty selective. We usually look for something that has some research already that indicated value, where the risk is low, and where we don’t have anything better to offer. The mind-body research has always outperformed expectations. I guess if you look at supplements, that is an area where we have not seen as positive of outcomes.
An area of focused interest for this reporter at the moment of the interview was the department’s “caring canines” services. Our family had just put down a much-beloved family member, a 17-year-old English Cocker, Esmeralda Kimball Weeks. Did Bauer have anything to say about the dog therapy:
How much time do we have? The volunteer canine program has been huge. We have a great group of volunteers. When we have a well-trained dog with a well-trained owner, it makes life better for patients, staff, everyone. Everyone stops to say hello. The families. The nurses. They are just a terrific addition. We couldn’t meet the demand so we got our own institutional therapy dog, Alta. By the time Alta gets on the floor, it takes 40 minutes to see one patient, as she and Jessica Smidt, the coordinator for the dog service, get stopped at least a dozen times along the way by stressed staff looking for a quick meeting with Alta. We just published a study with Purina where we look at the other side to check if providing these services is a stress to the dog. The dogs actually do very well. They had lower cortisol levels following their interactions with patients.
The integrative medicine clinical staff at the Rochester, Minnesota facility includes the following:
One standout characteristic is the longevity of the integrative practitioners as Mayo employees. According to data in the 2019 Integrative Medicine Program Report, the employment of all 4 massage therapists dates from 2008-2009. The licensed acupuncturists go back to 2007, 2011 and 2014, with two new hired in 2019. Alongside this information was a powerful “Key Highlight” that likely resounds well with those in Mayo’s C-suite:
Many patients continue to identify their integrative medicine consultation or therapy as the most important visit on their Mayo itinerary. This speaks to the high value patients place on having access to comprehensive care that focuses on all aspects of healing and health promotion.
Education and media
An additional measure of the value of the Mayo model is the reach of the Mayo team via national and international media. A 2019 annual report on the department includes a page with roughly 80 “selected” media appearances. The outlets are influential: New York Times, The Atlantic, Martha Stewart, PBS, Fox Business, Consumer Reports, El Mercurio (Chile’s top newspaper), National Geographic, and on and on.
Bauer and Mayo’s other integrative leaders have also produced a series of books and DVDs that have garnered acclaim and similarly spread the word about the potential value of integrative methods. The Mayo branding on a 12-part DVD series on The Science of Integrative Medicine offers the kind of value-by-association that the Harvard name gave to “complementary and alternative medicine” conferences in the late 1990s. Neither does it hurt that the series of lectures from Bauer was created in collaboration with Great Courses. Asked if another volume was in development, Bauer shared a lesson as a way of saying no: “Books and DVDs have a short shelf-life. So many things are changing so fast. They are outdated so quickly.”
Mayo provides some limited continuing medical education on integrative topics. Thus far, it hasn’t attracted the ire of the Accreditation Committee for Continuing Medical Education (ACCME). Bauer shared his view on why they’ve not been targeted:
We’ve never had an issue with [the ACCME]. We’ve done our homework. Then again, we don’t really push the envelope. It makes us less of a target. We’re not leading the change for the next cool integrative thing.
An area of enduring educational value is an in-depth course that trains massage therapists for work in integrated and inpatient settings. Until COVID, Mayo typically educated a cohort of 8-10 massage therapists two times per year. Bauer estimates that they’ve educated 100 massage therapists in this specialty thus far.
Mayo has a long-standing relationship with Northwestern Health Science University. Bauer qualifies the inter-institutional connection as:
” … good friends for a long time. We’ve had their massage therapists come down and we’ve gone there to give talks. We have a nice warm relationship. Now it’s the time and the money that are now the limits. Who’s covering the costs? Who’s covering the FTEs [Full Time Equivalents]? The philosophical issues are gone. Now it’s how do we validate the value we bring, especially with a shrinking pie.”
“Philosophical issues gone” – “a societal thing now”
The reference to resource limitations recalled a phrase Bauer used when I asked whether the growth of integrative services continued after the 2013 endpoint in the chart above. He had stated that while growth has leveled off a little, “demand is always outstripping capacity.” Demand, a.k.a. patient interest and satisfaction, apparently, is not enough. Nor is demand plus the science produced under the Mayo model. Bauer spoke bluntly, with an interesting word choice, about the limits to the inclusion of integrative services:
The limiting factor at this time is mostly societal. If a patient wants it, few would say no – they say ‘that’s fantastic – but is it covered?’ I think it’s a society thing now, that it’s not covered.
The “societal thing” is money – the decision by public or private entities to make the investment in services and relationships. The barrier brought to mind the remarkable action in 2017 by the National Association of Attorneys General. The organization stepped out of its usual lane on a societal issue, appealing to insurers to help fight the opioid crisis by covering more non-pharmacologic services. Bauer’s comment on limits also reminded me of a poem by the 19th century French poet Arthur Rimbaud in which the protagonist’s overtures toward a relationship are blunted by a query about his job status.
Bauer believes “we can help the societal thing.” He points to the pain guidelines supporting non-pharma approaches that the Joint Commission promulgated after the Consortium’s work in promoting an evidence review. The accreditation tweak by the Joint Commission mandate adds a modicum of police power toward what Bauer envisions: “It always comes down to the patient. If we open the integrative tool-kit, we have 10-20 different things we can do for patients. The evidence based approaches need to be on the table.”
In Bauer’s account, Lucy Gonda’s strategic investment helped propel Mayo clinical care to a point in which the “philosophical challenges” to integrative medicine and health may no longer be barriers. Raw prejudice no longer dictates whether formerly denied classes of non-pharma practitioners and services are included, and more expansive, cross-cultural, interprofessional, and inter-institutional relationships are considered.
Yet the “societal” challenges that remain are, to use a framework from another contentious policy arena in the United States, historic, economic, and structural. Might the Mayo model, in the present era of integration, demand of itself, of insurers, and of policy makers that the mind of its patient interest and research evidence have a chance to be united with the body of its economic, coverage, and delivery priorities? Mayo prides itself on being extraordinary.