In the mid-1980s, editor of Holistic Primary Care Erik Goldman began a career as a medical reporter. It was a boom-time for pharma-sponsored print publications. Each month mounds of media arrived at each medical doctor’s doorstep. Goldman’s first reporter job was with Dermatology News. It was what he calls “the height of unfettered spending” by big pharma. Goldman”s personal interests in natural medicine made him feel “an imposter – like they’d find out about me somehow.” By the early 1990s he was encouraging his editors to dip into the emerging “CAM” world. He unsuccessfully shopped the idea of focused holistic medicine publication to publishers before realizing that the “someone” just might be him. In 2000, he teamed up with with publisher Meg Sinclair and co-founded Holistic Primary Care which now goes out to 60,000 mainly conventional practitioners. I caught up with this fellow who is the integrative field’s most legit and enduring medical reporter – and presently sponsor of the Practitioner Channel Forum – to reflect on the two decades and look forward.
Goldman and I have had a relationship since I was on the receiving end of a call when he finally got his then employer International Medical Tribune, to allow him to write up something about alternatives. Goldman was recently featured in the Integrator (Understanding Google’s Censorship of Integrative Content: The Holistic Primary Care Case) after he shared the powerful impact on HPC‘s traffic of Google’s changed algorithms. UpShots, HPC’s monthly e-newsletter, currently reaches 20,000 professionals and HPC Practitioner Channel Forum has become a key intersection for the natural products industry to learn about their practitioner market.
Integrator: It was a startling call when I was executive director at the American Association of Naturopathic Physicians [AANP] and a call came in from some reporter who sounded like he wanted to treat us respectfully yet was associated with something called the International Medical Medical News Group [IMNG]. Respect wasn’t the media’s dominant mode back then.
Goldman: Well, it took some doing on my end. I’d been asking my editors at IMNG if I could cover the developments in the CAM space since I took the job as their New York Bureau Chief. They were reluctant, and not because they personally felt negatively toward things like acupuncture or nutrition. But they were of the mindset that their mainstream MD readers were not interested in these things, and they didn’t want to go out on a limb and cover things that their readers would likely perceive as “quackery.” It wasn’t until David Eisenberg and his colleagues at Harvard started hosting those “Intro to CAM” meetings in the early 90s, that I was able to get IMNG to see the light. Finally I had some mainstream legitimizing factor to which I could point. So my editors said, “Ya, well, OK … go ahead and give us an article about CAM.” That gave me a green light to call you. I was peripherally aware of naturopathic medicine, but being an East Coaster, I really didn’t know what it was about. But I wanted to learn.
Promoting the idea of a magazine like Holistic Primary Care
Integrator: I recall sending copies of your article out to members of the AANP’s House of Delegates – saying here, it’s possible – a report on the naturopathic profession that didn’t begin with dismissive caveats. You had a good job as a medical journalist. Why the hell did you decide to make the leap to found Holistic Primary Care?
Goldman: Well, it was good in the sense that it was okay income, and I could work from home. But it was tedious. I felt like an imposter as I heard about this or that drug, this or that procedure. I’d think it was wrong to just be focusing on medicine like that, but give no attention to prevention or health promotion, and I thought that the conference organizers would find out I was an interloper and they’d toss me out on the street. It seemed misguided at best. I wasn’t personally interested in conventional drug-based medicine. I didn’t think I was on the right side of history.
Integrator: Well those hard-copy newsletters and magazine and journals had their value – I went to school on mainstream medical policy during the Clinton reform when my family doctor sister-in-law Deborah Oyer, MD would save, and then then off-load bushels of them to me. How did you transition?
Goldman: I learned how the game works in publishing these kinds of periodicals – and wondered why there wasn’t one on holistic medicine. There was nothing out there. Burton Goldberg’s Alternative Medicine newsletters, not much more.
Integrator: Jonathan Collin [MD] had the Townsend Letter for Doctors where I got my Integrator-like start with a column called “Charting the Mainstream.” The American Holistic Medical Association had a quarterly magazine. There wasn’t much.
Goldman: The idea kept knocking about. My other life was on music-related projects. The turning point for me was a letter to the editor of the New England Journal of Medicine that had two doctors, Murray and Rubel, saying basically that all of our patients are using these alternatives, we should be talking about it. Then there was the publication also in the NEJM by David Eisenberg that showed a third of people were using these things and billions were being spent – and then the first Harvard conference and then [my editors] begrudgingly began to let me write on this.
Integrator: The publishers could run under the cover of the Harvard name. That was good for all of us. What a change that was.
Goldman: By the end of the 1990s, I pitched IMNG on this idea of starting up a publication along the lines of what we would create as Holistic Primary Care. This was a time when a number of pharma companies were starting natural product lines or buying supplement companies. Fredi Kronenberg was starting the botanical program with Andy Weil and others at Columbia. There was the Helms course for medical doctors to learn acupuncture. The naturopathic profession was taking off. Suddenly it seemed the mainstream was opening. I was living with Meg, whom I’d met through musical projects. I was having no luck getting anyone interested. Meg said “I think we should start it.” She is a pianist by training, but she has excellent executive skills, and at the time she was managing a boutique venture capital office. So we talked ourselves into jumping in. Other than a 9-month shut down after the September 11 attacks – we were based 7 blocks from the World Trade Center at the time – we’ve published 4 issues a year since.
The decision to target mainstream primary care doctors
Integrator: What was most remarkable to me was your target market.
Goldman: We saw our role then as we do now as building bridges between conventional allopathic medicine and the holistic healing disciplines. We thought the way to do this was by helping educate medical doctors about holistic, functional and integrative practices. We initially bought lists from the AMA Master File. We wanted to reach primary care doctors – family practice, OBGyn, and internists less than 55 years old. We figured there would be more openness in younger doctors. We’ve been building our own list since through people we meet at conferences.
Integrator: The business model has been to push HPC out there to a large group and get advertisers who want to reach them.
Goldman: In the beginning we had to literally give ads away. We were trying to go to family doctors and internists and most supplement company advertisers couldn’t believe this made sense. They’d ask us, “Why would we want to advertise to MDs?” and we’d say “this is where your growth will be.”
Integrator: What’s the split now in the professionals on your list – it’s a mix now, yes?
Goldman: It’s about 80% medical doctors, 10% osteopaths, 5% nurses, 2% each for chiropractors, naturopathic doctors and others. We know that a lot of them read HPC religiously, cover to cover. Many put it out in their waiting rooms. Some even thank us for it! Many are professionals who now identify as functional or integrative, but most are still mainstream practitioners. We’re trying to give them information that will open their minds.
The practitioners and the natural products industry
Integrator: For years you’ve been doing surveys and gathering intelligence from the field. What have been your surprises?
Goldman: We started the surveys in 2010, because people in the industry were asking us some very basic questions – things like “How many doctors sell supplements?” And we really did not know. And nobody else had any real numbers either. So we said, “Hey, let’s do a survey.” These annual surveys always ask questions about dispensing – selling – supplements and natural products. Back in 2010, that number was 30% of respondents did. And that number is up to 60% now. The biggest surprise finding was in 2016 when we asked these practitioners if they knew what “DSHEA” was. We intentionally did not say Dietary Supplement Health and Education Act [DSHEA] but used the acronym everyone in the industry uses. Many had no idea. Almost 60% of those who dispense supplements in their offices did not know about this fundamental federal regulatory law.
Integrator: Yes, there is a surprising chasm between “the industry” and these integrative practitioners-as-retailers. You’ve spent a good deal of time trying to bridge this gap. I’ve done a bit myself with it in the Integrator and elsewhere.
Goldman: This little data point made us realize that we needed to provide our readers with more education on how natural products are regulated, on quality control, and how all of that that works. There are problems with DSHEA, but when someone claims that supplements are unregulated people need to know that it’s not so. There are holes in DSHEA, but there is a basis for improving the quality. This has become an advocacy piece for us. The integrative and functional medical communities need to recognize the important role that the natural products industry plays in advancing holistic and naturopathic medicine, and at the same time, the industry needs to know more about practitioners, and to recognize that it is part of healthcare.
Integrator: Thus your annual practitioner forum for industry members.
Goldman: Yes. We celebrate our 20th anniversary of HPC on April 23 at the TWA Hotel at JFK Airport as part of our 2-day Practitioner Channel Forum. We’ll be examining some major policy issues this year – the Google actions. Our tech guys, Tyler Horsley and David Le Flore, who are savvy about this, will be there. And we plan to go into the Accreditation Council for Continuing Medicine Education (ACCME) issues that you’ve been writing about. It’s still a pretty small conference of 30-50, kind of a think tank. We are identifying areas of common interests. I’d like for instance to see practitioners at the table more when regulations are being developed. CBD [cannabidiol] is an example. I’d like more practitioners involved in the discussion about how CBD and other cannabinoids are regulated. We don’t want to be so cozy that it looks like a cabal. But it would be good if the industry were more tuned to the real needs of practitioners. Likewise, it would be great if more practitioners understood that most of the supplement companies really are well-intentioned, and trying to do the right things.
Perspectives on the ACCME and conflicts of interest
Integrator: Speaking of such a “cabal” – the ACCME [Accreditation Council for Continuing Medical Education] appears to be taking a hard line on practitioners selling products in their practices. The ACCME maybe even exclude such practitioners from being ACCME-recognized teachers of accredited CME. This is not certain, but it would be huge. Thoughts?
Goldman: The issue of conflict-of-interest around sales of supplements by practitioners is nothing new. The AMA took a formal position against practitioners selling products for profit many years ago. And some states have regulations against physicians profiting from product sales of any kind. To some extent this is a legitimate concern. As patients, none of us wants to be coerced into buying products by our doctors. But there are many different approaches. Some doctors sell products at cost, or at a very minimal mark-up. They want their patients to have access to the practitioner-only brands, but they don’t want to incur the appearance of conflict of interest. Many others do sell at higher margins, but that’s the only way they can underwrite the longer office visits that are typical in holistic, naturopathic, and functional medicine. But the issue of practitioner product sales is not unique to this field. Many dermatologists sell premium “MD-only” cosmetics and skin care products. Many dentists sell oral care products and devices. And many other types of physicians sell add-on, elective, out-of-pocket services or procedures.
Regarding the ACCME, I understand its concern. They don’t want doctors who are paid supplement industry consultants up there at the podiums pushing the products at CME conferences. But if they’re going to prohibit that, then they must also prohibit physicians who are paid pharmaceutical consultants or recipients of research grants from promoting drugs at CME conferences. I doubt they’re going to do that. So, if ACCME does take a stand against doctors who promote supplements, but not doctors who promote drugs, it would create a double-standard that I do not think is fair. But as we all know, the world is not always fair.
Integrator: There is definitely some self-regulatory work that the ACCME is asking of the field – relative to its relationship to the industry and to evidence.
Goldman: There is some strange “inside-outside” psychology in this field. Holistic and naturopathic practitioners want to be accepted by the mainstream, but they still like to be outside, to hold on to their “outsider” status. It’s the same with the industry. If they play to the mainstream, they’re not renegades any more. If they stay outside the mainstream, there’s a limit to their growth. The whole stigma in being alternative – a lot of people like being seen as “alternative” or “outside” even as they protest being called “alternative”. But the reality is, as the formerly rock-solid boundary between “conventional” and “alternative” medicine becomes more porous, our field will have to deal with the standards, the attitudes, and the biases inherent in the conventional allopathic world.
New responsibilities and “impacting the major issues of our day”
Integrator: With respect comes responsibility, in my view. Is there a push for a different type of responsibility from the industry reflected in the Holistic Primary Care editorial line?
Goldman: I’ve not thought about it exactly like that. What I do see is that the field needs to see itself as part of the larger issues. The Google issue is one. Climate change is another. The climate issues are health care issues, and integrative and functional have a big place there. We are reporting in these areas. We are doing a lot about food. Now we’ve got the Corona virus. This epidemic is already causing massive raw materials supply issues for the industry. A lot of raw materials are sourced in China. There will be shortages for months to come. And concerns about Coronavirus led to the postponement of Natural Products ExpoWest in Anaheim this month. This is a gigantic trade show. They were expecting around 90,000 this year. But there were so many last-minute drop-outs and a lot of industry push-back, that New Hope Natural Media—the Expo’s organizer—was forced to call it off the day before it started.
The point here is that this field is not the tiny band of renegade upstarts it was 30 years ago. It is a very significant segment of healthcare. And it will be affected by—and it can potentially have impact on—all the major issues of our day. We need to recognize that. We take the term “holistic” seriously. It means being able to shift focus from the micro to macro levels. This is something I’ve always admired in (Institute for Functional Medicine founder] Jeff Bland – the way he moves fluidly from the environmental to the genetic and back. In our own way at HPC, we try to do the same. Yes, we report on the studies showing how a particular probiotic strain might affect inflammatory cascades in people with irritable bowel disease. But we also report on big picture issues like atmospheric carbon and the value of regenerative agriculture and soil sequestration. All these systems and levels are interconnected. At HPC, we are also finding it important to report on tech, on genomic testing, on the microbiome and wear-ables. Tech people are very interested in healthcare these days. And they want to disrupt it. These tech tools are cool on the face of it but how do you really implement them in a busy medical practice? What do busy doctors really want—as opposed to what engineers and programmers think they want?
The problem of developing successful business models
Integrator: We have the continuing issue of business model. How do people make their practices work financially? It was tough going 20 years ago when we realized that so much was structurally weighted against the field taking off and thriving.
Goldman: We’re stuck at a tipping point. It never really tips.
Integrator: What’s your answer as to why?
Goldman: The economic infrastructure, the incentive structure, the whole framework keeps us stuck. Most [integrative and functional] practitioners are not taking insurance. People who want this kind of medicine must have the dollars to pay for it. And many don’t have the cash. It’s a straight up money situation. We’ve been doing what we can. We were early to talk about the group visit model. Our seven Heal Thy Practice conferences from 2009-2015 were all about practice models that support holistic modalities. Those conferences were impactful in that they helped a number of practitioners – including several now-prominent ones – create thriving practices that really do deliver good quality holistic and functional medicine. So, yes we can help some individual practitioners and their patients. And that’s been very positive change.
But the larger systematic obstacles really have not changed much since we started HPC 20 years ago. Those bigger changes will require a level of political will and economic pressure that we’ve not yet seen. As long as most Americans are dependent on insurance for their healthcare, and as long as the big employers will continue to pay rising premiums for the same-old, same-old standards of care, and as long as Medicare and Medicaid continue to resist embracing holistic approaches, the mainstream systems will continue do what they’ve always done. They do what they’re getting paid to do. It is that simple.
Integrator: It’s 2020 now. Where from here?
Goldman: A really good question. Looked at from the biggest picture perspective – and I’m not going to put a “should” on it – we have to ask will this field forever be a set of boutique practices, a side-dish to regular medicine, only available only to a small segment of relatively well-off people? Or will there be a charge so that this approach to medicine can be much more transformative for many more people. The whole move to integrative or functional is a very scary transition for individual practitioners. For the first year or two they take a loss. Income may never be what it could be as a salaried employee working within in the system. The concept of private practice is hardly even being taught anymore in medical schools.
Integrator: The field still needs to make its case – for why for instance a doctor’s time may be more valuable in a long visit, engaging behavioral determinants of health, for instance, rather than in a short visit that presently brings the most income per minute.
Goldman: I don’t see the insurers being friendly. The leverage needs to be the employers. They’re the ones ultimately paying the bills.
Integrator: And the government agencies as employers and their public programs. I’d add unions too as potential partners.
Goldman: Medicare really does set standards for other insurers to follow. But look how long it took for Medicare to begin covering the Dean Ornish lifestyle change programs. These agencies move slowly even though so much is at stake. One thing for sure – we have to drop the renegade thing. We have to drop this narrative around “alternative” versus “conventional”. This is about common sense care.