“Integrative light.” The term began to be used in the late 1990s by some community-based holistic, integrative, functional, and naturopathic medicine practitioners to discount and dismiss actions in the then emerging field of academic integrative medicine. I was reminded of this knee jerk tendency toward disparagement recently when a past president of the American Holistic Medical Association (AHMA) sent an email query asking for names of any medical schools that “really support integrative medicine and have legit programs.” The question fell within days of receiving an annual report from one such center born in that period 23 years ago, now the Osher Center for Integrative Medicine at Northwestern University in Chicago’s downtown. It struck me that it might be useful to examine the myriad ways that at least one such entity is at work to shift medicine toward a healthier model.
While I had my own guesses of what he meant, I asked my colleague from the AHMA – now a part of the Academy of Integrative Health and Medicine – what he meant by “legit”. This was the useful response:
I mean walking the talk, being sincere, not just window dressing, really moving the field and the conversation forward. Real clinical care in the model, influence on the community, research too but if not doing the others I see it more as window dressing or mental you know what.
This column is a sort of response. The Northwestern Osher Center is among the premier academic integrative operations among the more or less four score members of the Academic Consortium for Integrative Medicine and Health. Thus I am stacking the deck on the larger question of academic integrative medicine’s contributions. And yet the spread of integrative activities underway at Northwestern provides insight into the multiple yardsticks that might be utilized to measure “legitimacy” across the array of engagement of these academic players.
Northwestern Osher is directed by an individual who clearly has a knack for attracting resources and making things happen, Melinda Ring, MD, FACP, ABOIM. When the Duke Leadership Program sought to add faculty with success in running a significant integrative center, they invited Ring as core faculty. An internist who is also a 2004 graduate of the Fellowship in Integrative Medicine from the University of Arizona Andrew Weil Center for Integrative Medicine, Ring is presently the Drs. Pat and Carl Greer Distinguished Physician in Integrative Medicine at the Feinberg School of Medicine. She is joined in leadership by Nancy Heap, MSW, LCSW, director of program development.
Ring shared with me a slide presentation she has used for the Duke program, the Center’s 2020 annual report (see 2018 and 2019 here), and 60 minutes of her time for an interview. From these I plucked some representative contributions across the clinical-education-research-policy continuum.
While the label “INTEGRATIVE MEDICINE” is written large in this schema, the Center and its services are small players in a sprawling medical delivery organization. Northwest Memorial Healthcare has assets of over $14-billion and patient revenue in FY2020 of over $6-billion.
The Clinical Model – Primary Care
The integrative center began in 1997 with one medical doctor and one behavioral specialist. Today, they have grown to include 3 primary care integrative medical doctors, and an integrative advanced practice nurse. The present team also includes 3 East Asian medicine practitioners (who use not only needles but herbs and cupping), a chiropractor, 3 health psychologists, 3 body-workers and 3 registered dieticians. In the past, the team has included a naturopathic doctor. As of FY 2016, the Center registered 28,800 outpatient visits. The services have been growing since.
Ring shares that part of the model’s success came from the decision to locate the integrative service line inside of primary care. Hospitals are accustomed to viewing primary care as a loss-leader:
We envisioned primary care for two reasons. First, primary care is known as a loss leader in general. It’s accepted in the system to lose some because of its value to the bigger system for its referrals for tests, labs, and surgeries. Losses weren’t so directly attributed to the “integrative” work. Second, housing integrative medicine within primary care creates a more fluid source of referrals to integrative/complementary medicine providers. Our vision was to create an integrative PCMH [Primary Care Medical Home] where patients could receive both preventive, proactive care and more conventional biomedical care.
The assumption about referral creation appears to be working. “Last time we looked,” reports Ring, “roughly a half of referrals of new patients are coming in from physicians and half are patient-initiated.” She mentions that rheumatology and endocrinology and other primary care are presently some top sources.
With the “legitimacy” question in mind, I note that Ring’s presentation makes a point of sharing that the team’s East Asian medicine practitioners aren’t merely tools for delivering needles. They are bringing a broad set of the whole practice to patients. I asked Ring about what restrictions she or other practitioners put on their integrative services. Are there treatments that they might not include that are more common in community practices? She was candid.
I’m personally left of center but not so far as to fall off the edge. I won’t recommend HCG diets, for example, where there is clearly a greater risk of potential harm than most other dietary interventions. Chelation is another treatment we don’t offer. I do functional medicine as do my fellows. This includes some things that are not fully accepted – stool testing, hormone therapy, thyroid treatment beyond Synthroid, food sensitivity testing. When we do them, we talk to the patients about the current state of evidence, the risk-benefit, and we document that we are communicating any variance from ‘standard-of care.’ We tend to stay away from diagnoses like mold-toxicity, because the tests don’t meet our standards for accuracy. Similarly, we’re not big on some other areas that are popular with functional medicine doctors like chronic Lyme disease treatment, and yeast overgrowth. My ultimate question when considering functional tests and approaches is whether there is evidence that acting upon the results will correlate to a change in clinical outcomes.
The clinical services do not end in the primary care clinic. Osher Center practitioners also support some inpatient care.
As a part of an academic medical center, the Northwestern Osher Center has an ongoing engagement in research. They summarize their research foci this way: “CALM, which includes mindfulness and yoga; STABLE, which includes approaches such as acupuncture and tai chi; and INFINITE, which includes nutrition and food as medicine.”
Topping the research team is Judy Moskowitz, PhD, MPH, the Center’s director of research. Moskowitz has grants from multiple NIH agencies. Her lab website is here. Moskowitz is currently president of the International Positive Psychology Association. Another contributor is David Victorson, PhD, a leading mind-body researcher nationally who directs the Consciousness in Health Research Lab. He has been trusted, for instance, to co-lead an NIH National Center for Complementary and Integrative Health (NCCIH)-funded project that is seeking to advance all research in mindfulness by standardizing measures.
The following 8 projects are among those from Northwestern Osher principals that are featured in the Center’s 2020 Annual Report. They are listed with the principal investigators and the chief funders:
The portfolio highlighted here is long on mindfulness and well-being, with a good deal of practical focus. Viewed from a historic vantage point, it may be seen as necessary remedial work to stitch the biomedical body and mind together for those who abusive medical upbringing separated the two in the first place. While 25 years ago many, including the present writer, tended to dismiss reductive projects for failing to examine the multi-modal, whole systems that are the heart of all integrative clinical care, it is clear that the steady accumulation of such studies are beginning to influence the emergence of more whole person treatment guidelines in the areas of pain treatment, and elsewhere.
Northwestern Osher’s education programs range from a two-year Clinical Fellowship to culinary medicine. At the top of the ticket is the Fellowship, jointly engaged with another of the 7 Osher Centers, this one at University of California San Francisco. They have recently completed development of an Osher Collaboartive Fellowship Curriculum, which they hope to scale to increase access.
Northwestern’s second graduate of the full two-year clinical fellowship program, Anna Shannahan, MD, stepped into a position as associate education director for the Center while also supervising residents at an affiliated outpatient center. The 2019-2021 clinical fellow, family doctor Amrien Ghouse, DO is a family medicine physician who is expanding her clinical tools through training in a Japanese style acupuncture and in functional medicine while also working to develop the culinary medicine elective with Dr. Ring.
Ring is pleased with an a new Faculty Fellowship that is provided to current Northwestern physicians wishing to explore integrative paths. The first 5 participants hail from 5 different medical specialties: rheumatology, family medicine, pediatrics, emergency medicine and anesthesiology. It’s not lost on Ring that each of these becomes an emissary for integrative medicine in another part of the sprawling system:
They are bringing it back to their departments. Our ER doctor in the program is doing motivational interviewing around nutrition, as an example. This is what [former Harvard Osher director and now NCCIH director] Helene Langevin calls ‘integrative medicine w3ithout walls.’ There’s more credibility. There is more impact.
Other educational offerings include programs for undergraduates and electives for medical students. Ring is also proud of their Cooking Up Health culinary medicine program to get “Docs and Kids in the Kitchen.”
While not part of the big three of clinical-research-education, the alpha and the omega of what can be done is arguably the policy and related funding context. Ring, as director of the center, has directly contributed in multiple ways. Her core faculty role at Duke, alongside Veterans Administration Whole Health lead Ben Kligler, MD, MPH, for instance, is an investment in educating a new generation of proselytizing integrative health leaders. Similarly, when the field realized the need to establish a board certification via the American Board of Integrative Medicine, Ring first gained the certification – one of 850 now recognized – then began service on the board. She presently serves as the board’s vice chair.
In the past two years, Ring chose to directly engage one of the more pressing issues for the flourishing of integrative medicine in the years ahead – the increasing hostility of the Accreditation Committee on Continuing Medical Education toward integrative medicine continuing medical education programs. Ring contributed to a national task force of integrative CME providers that has met to address the multiple issues raised. Most agree that the ACCME highlighted some issues of merit while also harboring unacknowledged bias. With colleagues from two other Osher Centers, Ring co-authored and had published in the peer review media “Keeping Integrative Medicine Continuing Medical Education on the Cutting Edge – and Compliant”. They both called out the bias and recommended steps forward for the field.
There was a time in the emergence of academic integrative medicine when straying beyond research and education about the contraindications for prescribing herbs was considered a radical move. Ring and Northwestern, with their reputation for their clinical offerings, played an important role in prying open the field 2013 when, after the Consortium had held 3 research meetings and one on education, Northwestern hosted the Consortium’s first clinical conference. The Northwestern program has also helped push academic integrative medicine in another important real world direction through hosting the 2017 conference of Integrative Medicine for the Underserved (IM4US).
Concluding thoughts – paraphrased from Everett Dirksen
To be a member of the Consortium, an integrative academic medicine program must show evidence of integrative activity in at least two of the top three defining areas of influence: research, education, and clinical services. Policy is a fourth domain, not considered in the Consortium’s membership calculation, but a part of activity in most academic health centers. Northwestern Osher under Ring’s direction is hitting on all cylinders.
A former US Senator from Northwestern’s home state, Everett Dirksen, is famous for a quip he made relative to expanding federal budgets. A billion here and a billion there, he reportedly stated, pretty soon you are talking about real money. A few research projects here and expanding clinical services there. An integrative fellowship here and an integrative elective there. Supporting board certification here, and taking on prejudice at the ACCME there.
Pretty soon, to respond to my AHMA colleague, you are talking about real legitimacy.