The idea that “the first is the last and the last the first” was a value in my liberal Protestant upbringing. It likely had some noblesse oblige in it too. The concept can be challenged as an entrapping promise that good will come of waiting. Regardless, in some the call to work with the least-cared-for becomes a guiding mission. Self-preservation of the integrative field may be another motivator of such a mission. A past head of the NIH agency that researches integrative practices has challenged the main body of clinical research as un-generalizable due to the research being on upper income, well-educated, white, female patients. For a multitude of reasons, Integrative Medicine for the Underserved (IM4US) has emerged as the leading edge of the movement for integrative health.
I worry about capturing information from a non-representative subgroup of the population [such as typically visits practitioners in academic integrative centers where much research is carrier out]. As the steward of the public dollar, we have to worry about making sure that research resources we support capture information that reflects the socioeconomic and other kinds of diversity of the country. Unfortunately, that is not necessarily well captured in some of the existing integrative centers.” – Josephine Briggs,MD, past director, NIH National Center for Complementary and Integrative Health (2016)
The IM4US’ 9th annual conference, Solidarity & Self-Care – Supporting Social Justice and Balance in Integrative Health was hosted by Santa Clara University August 22-24, 2019. Many of the 300 participants chose to be housed in dorm rooms, keeping costs down. I say “participants” as IM4US’ mission begins with empowerment and engagement practice like health coaching, self-care and group-delivered services. They are evident in the conference sessions even as they are wedged into the clinical environments of the federal qualified health centers (FQHC) and other community centers with which the majority of participants were associated.
I was an interested participant, as a member of the IM4US advisory board. Here are snapshots and reflections from two days in the professionally, racially, culturally and economically diverse mix of committed souls. The 10th will be at the University of Wisconsin August 27-29, 2020. Be there!
Born out of Family Medicine Teachers; Assertively Interprofessional
Fifteen years ago, the integrative medicine section of the Society of Teachers of Family Medicine birthed a subgroup focused on strategies for bringing integrative medicine to underserved populations. Within a few years, their doors and Board of Directors opened to nurses, acupuncturists, naturopathic doctors and others. Since 2016, membership has shot up from 120 to 400. (Join!) A key shot in the arm was a multi-year $150,000 grant from the Samueli Foundation that funded infrastructure for what had been an all-volunteer effort. Samueli remains an investor. The George Family Foundation is now also a $25,000 partner. A significant set of organizations and funders now chip in, including the Academy of Integrative Health and Medicine. Recent transformative organizational news: volunteer president Priscilla Abercrombie, RN, NP, PHD announced that former Board member Rhonda Smith has been hired as the organization’s first executive director.
With its significant links into the Academic Consortium for Integrative Medicine and Health, the Academic Collaborative for Integrative Health and the Integrative Health Policy Consortium (IHPC), IM4US has become a community-wide enterprise, addressing a significant gap. Notably, a founding IM4US board member and policy leader Sharad Kohli, MD is in line to become the new president of the 27-organization IHPC.
Integrative Medicine without (So Many) Supplements
It is notable that only one dietary supplement company was among the conference sponsors. The 2019 conference of the Integrative Health Symposium boasted over 200 exhibitors with the vast majority selling supplements. 120 booths, similarly characterized, exhibited at the recent conference of the American Association of Naturopathic Physicians. The IM4US populations can’t afford bags of supplements. And while an FQHC may make a few available, their payers generally don’t cover. Besides, continuity in supplement-taking regimes fits less well with lives beset by present and past traumatic disturbances, economic challenges and irregularities.
The reality begs a question: How then does one best provide integrative health without leaning on or stimulating change with these natural pharmaceutical agents? The forced exploration is not so much a return to roots as it is a finding and putting down of roots with these populations in these clinical environments. The undertaking has broad resonance. The challenge to maximally serve with integrative health through few if any supplements jumps borders to the Veteran’s Administration. There the Whole Health model focuses also on low-cost self care, peer work, groups and community. Similarly, the models explored and on display at IM4US will likely also be those that will open integrative doors to the vast majority of USA citizens for whom care is received through hospitals and other medical delivery institutions. The integrative healing without supplements exploration makes IM4US a critical cookhouse for the field’s future.
Group Services: Research and New Directions
Three years ago IM4US chose to prioritize expanding access to, and coverage of, group-delivered services as one of its top two policy initiatives. Last year the organization partnered with JACM-Paradigm, Practice and Policy to Advance Integrative Health (The Journal of Alternative and Complementary Medicine) on a Special Focus Issue on Innovation in Group Delivered Services. A session on the JACM content with which I was involved and that included Maria Chao, DrPH, MHA and Marena Burnett was sandwiched between a half-day interactive pre-conference focused on the use of group services in “health justice” and an energetic research session led by Ariana Thompson-Lastad, PhD. The latter drew nearly a quarter of the conference attendees to explore methods for doing research on groups. It was a remarkable showing of enthusiasm that quickly channeled into teams of those with similar interests. Interest areas ranged from diabetes care to using groups to release providers from burnout. Emails were shared, collegial relationships forged, and the potential workforce organized. Meantime, author and Evomed/Functional Forum founder James Maskell was pulling key leaders aside to interview for his upcoming book on integrative group services.
With the resonance of group visits with the principles, values, lifestyle and behavioral determinants foci of the integrative medicine field, there is opportunity for leadership of the field in promoting a vast expansion of group-delivered services as leverage for transformation of the medical industry. As I asked in my JACM column: Do Group-Delivered Services Belong Closer to the Center of a Transformed Health Care System? IM4US is taking it on. Discussions of a more lengthy training were percolating toward a 2020 pre-conference session. Stay tuned.
Integrative Medicine Access Announces New Benefit for Participating Practitioners
Interested in providing services to the underserved with part of your practice? Myles Spar, MD, MPH, a past IM4US board member is founder of the aligned not-for-profit Integrative Medicine Access. It’s goal is to link integrative practitioners who are interested in volunteering services at their own clinics – at the level they like – with underserved patients who could benefit. Spar shared a new benefit to practitioners who participate in IMA. They gain access to the Helpsy Health tools. The business calls itsself “the World’s First Virtual Whole Health Nurse for Symptom Management and Pain Management.” (Past Consortium and IHPC special adviser Margaret Chesney, PhD, is on the Helpsy advisory board.) Clarifies Spar: “Basically the partnership allows practitioners who sign up for IMA to have the use of the Helpsy health platform for free. It offers self care and integrative medicine tips for patients though an app. It’s an easy way to teach patient self reported outcomes.”
Santa Rosa Passes on Skill Sets: The First Integrative Residency focusing on the Underserved
The intent classroom picture above was from the session led by IM4US co-founder Ben Brown, MD and Wendy Kohatsu, MD and a team from the Santa Rosa Community Health Center. The center has a claim to being the first West Coast FQHC – over a decade ago – to have an integrative medicine residency. Brown shared that through the experience the center has “become a destination site for how to do integrative medicine for the underserved.” Brown shared that a quiet long-term strategy was having hoped for effects: with the attractiveness to practitioners of Santa Rosa’s integrative offerings, the other community clinics in the county have been required to build integrative offerings to attract new practitioners. Before inviting the participants into affinity-based groups, they offered their lessons into three buckets: what can be implemented immediately (including Brown’s well-acted “bathroom shake”), what can be done with some time and attention, and those actions that will require system change. They laid out their Friday morning “integrative medicine consult” strategy. Perhaps 80% of the attendees were practitioners similarly located in community health centers, eager to learn any tips.
Geller’s Move To Pioneer a Group-Centered Primary Care Practice
In the room for the Santa Rosa talk was the acknowledged dean of integrative medicine group visits, Jeff Geller, MD, MPH. Geller had the first integrative residency focusing on the underserved. His wisdom after working countless groups over 20 years was evident as he worked with the group that participated in the pre-conference noted above. “Did you see what I was doing there?” he’d chime in here and there as participants were nudged into letting go of directive, top-down communication to allow a group the freedom to take its own leadership.
In a brief interview, Geller shared that he recently left his FQHC and is bringing a population he has served for now two decades in his community into a practice he is designing to have group at the center. Geller – who has published 7 research articles on his work including recently on the “group inclusion effect” – intends to continue research on his new, radical model. Geller and JACM special issue co-editor Paul Gardiner, MD, MPH will lead a training September 14-15, 2019. A James Maskell podcast with Geller is here.
Michelle Steinberg, MS: Getting out the Word Via Documentary
The Friday evening out-door reception was followed by a screening of a documentary in development by nutritionist, herbalist and director/cinematographer Michelle Steinberg, MS, an IM4US board member. The film on which she is partnering with producer Robyn Bykofsky is topical, portraying two immigrant families receiving care through community clinics after suffering distinct but parallel kinds of refugee trauma. One is from the Republic of Congo where wars ripped up the fabric of life and and another from Cambodia’s long shadow of the Khmer Rouge. It will be called A Place to Breathe. The documentary “explores the universality of trauma and resilience through the eyes of refugee and immigrant patients and medical providers.” The clips shown were yet additional reminders of how far these delivery centers and their clientele are – geographically and economically – from boutique, cash-based integrative practices – or even community acupuncture, naturopathic or holistic clinics that may serve middle class clientele.
Open Source Wellness: Putting the Community in the Driver’s Seat
On Thursday, author, promoter and podcaster Maskell opened my eyes to making sure I attended the Friday keynote via a challenging question he put to me. We were talking about the movement from sick-care to wellness and from reductionism to wholism. Do you really think that the institutions that brought us sick care will be leading us into wellness? “Might it be,” he offered, “more likely that leadership will come from community based initiatives like the keynote Elizabeth Markle is doing with Open Source Wellness?”
The talk’s title was the organization’s cut line: “Community IS Medicine.” Markle, who co-founded OSW with Ben Emmert-Aronson, PhD, appended this to the title: “Animating Clinic and Community as Platforms for Human Health and Well-being.” Their site uses the catchy phrase that “When ‘I’ Becomes ‘We” Even ‘Illness’ Becomes ‘Wellness'”. In TED Talk style Markle took us into their Oakland context where the idea germinated and now is expanding into the Northwest. “Shame” is an emotion she said that is “upstream” for these communities – and “despair” is further upstream than shame and “violence” and trauma further up yet. “I’m not totally convinced,” Markle reflected soberly, “that saying ‘exercise! eat better! see you in 6 months’ is not doing harm.” Open Source Wellness calls their offering “Behavioral Pharmacy” – underscoring that this is “medicine” and presumably not merely prevention or wellness. Paradoxically, they de-medicalize or better said de-behavioralize the pillars of health. No mention of “exercise.” Instead: “move”. No “diet”. Instead “nourish.” No “isolation” or “depression.” Instead “connect”. No mind-body or spirituality. Instead “Be”. Intoned Markle: “You will hear these a lot from us.” And they are not stuck on these. She offered one alternative: “Play, Belong, Give, Love.” The model is here.
The Church I represent is the Church of Good Health
There’s one thing that with the others we have in common
That is for you to respect God, you must be separated from Mammon.
A part of my job is to release you from your wealth
-Reverend Nat Patrick (an alter ego, 1986-1989), auctioneer for natural health, Bastyr College
Asked by friends and colleagues about the IM4US conference experience – which I first had last year — I am again relocated in the values from my parental home noted at the top of this column. My parents expressed their activism in interdenominational and interracial engagement through the United Council of Churches, Seattle’s – and their church’s – open housing and then open-and-affirming movements. It was a rich and wild mix, especially given our 1950s-60s West Seattle community defined mainly by the mono-culture of families of Boeing engineers and machinists.
IM4US is an overlay of integrations on top of integrations: interprofessional, national, racial, and economic. They are fused together by shared commitment to serve those with the least among us, to make the last first in their professional work and integrative practices. These rich combinations, rare in most other integrative gatherings, characterized every breakfast table of mixing long-time friends and meeting new people, each small breakout, and the walks between conference rooms across the campus. It’s rare. It’s stimulating. These explorations and directions on which IM4US is leading are necessary if the field is to shuck its stigma and reach the whole. It’s a powerfully heart centered movement within the broader movement. Consider Milwaukee for the 10th annual IM4US in August 2020. Open your perimeters.