Summit Overview and Background (Chapter 1)

Setting the stage for the summit discussions, Dr. Harvey Fineberg, president of IOM, said that in speaking to people about integrative medicine before the summit, he felt as if he were showing them a Rorschach blot and asking, “What do you see?” Integrative medicine, he said, means many different things to many different people and has at least five critical dimensions:

• Broad definition of health: Integrative medicine offers the possibility to fulfill the longstanding World Health Organization definition of health as more than the absence of disease. It should include physical, mental, emotional, and spiritual factors, enabling a comprehensive understanding of what makes a person healthy.
• Wide range of interventions: Integrative medicine encompasses the whole spectrum of health interventions, from prevention to treatment to rehabilitation and recovery.
• Coordination of care: Integrative medicine emphasizes coordination of care across an array of caregivers and institutions.
• Patient-centered care: Integrative medicine integrates services around and within the individual patient, which is perhaps the most fundamental and the most neglected aspect of high-quality care.
• Variety of modalities: Integrative medicine is open to multiple modalities of care, not just usual care, but also unconventional care that helps patients manage, maintain, and restore health.

Snyderman talked about the great difference between health and well-being and the care Americans currently experience. He acknowledged that many of the ways to improve health must be actively promoted by individuals themselves, and cannot be accomplished through the health care system. “Even the best health care system, acting alone, cannot assure good health. It needs the individual’s engagement and commitment to health,” he said. He described the first transformation in medical care, which occurred almost exactly 100 years ago, when advances in science resulted in the identification of microbial factors of disease and provided a new way to practice medicine. An unintended consequence of this transformation was development of the find-it-and-fix-it approach to medical treatment that focuses on identification and treatment of disease. Now, he suggested, is the time for a second transformation—one that again would be propelled by new advances in science, which for the first time are providing capabilities for quantifying health risks and the benefits of individualized therapies. This revolution could transform care into personalized, predictive, preventive, and participatory health care that would promote health and well-being.

The Vision for Integrative Health and Medicine (Chapter 2)

The panel discussion on vision underscored the notion that the current health care system is fragmented and not oriented to health promotion or disease prevention. Panel moderator, Dr. Michael Johns, for example, noted that much of today’s health care system focuses on treating major, often fatal, diseases, but these efforts are not sufficient to achieve a healthy population. Bill Novelli described the large contribution that Americans’ individual behavior choices make in preserving health or causing diseases. Yet, the health system is not currently geared toward supporting individuals through the long and difficult behavior change process. The health system might be more successful in eliciting behavior change if it were supported by policy changes, coordinated action across social sectors, community-based efforts, and more robust and diverse patient-education efforts, as described by Dr. Mehmet Oz. As he described his vision, Dr. Victor Sierpina noted that clinicians will need a different kind of education to work in a more integrative and community-based way.

Panelists discussed options for more integrative care efforts, including expansion of the pool of primary care providers suggested by Sierpina and use of multidisciplinary care teams. Such efforts can be greatly enhanced by electronic data systems that provide comprehensive patient-centered information to caregivers in a timely way, George Halvorson said. These systems could be the underpinning of a system for more patient-centered care. Ellen Stovall emphasized that clinicians must recognize that many of the skills patients need to actively participate in decision making about their care evaporate in the face of a serious illness, necessitating a greater need for patient-centered care that involves attention to patient preferences and integration of mind, body, and spirit.

Models of Care (Chapter 3)

In the session on models of care, speakers described various existing models of integrative care and highlighted principles that are vital to the success of future models. Speakers referred to almost a dozen different models that incorporate integrative approaches. These models have been implemented in a variety of settings and address acute care, chronic disease management, and home-based care. Throughout the session, patient-centeredness was the key theme.

In his keynote address for the session, Dr. Donald Berwick suggested that true patient-centeredness would attempt to explore patients’ deep feelings about their health goals, so that care decisions would most effectively serve them and enhance prospects for successful treatments. He remarked on the notably generous spirit and common purpose reflected among summit participants, despite remarkably diverse perspectives. He underscored the importance of that sense of unity, given that the natural inclination of professional groups is to make a case for their treatment specialty, often at the expense of the patient. To avoid this fragmentation, he said, the first challenge for integrative care will be for the field to define what is being integrated, why, and then ultimately to integrate itself.

Drawing in part on his previous IOM committee work, Berwick proposed the following eight principles for integrative medicine:

1.

Place the patient at the center.

2.

Individualize care.

3.

Welcome family and loved ones.

4.

Maximize healing influences within care.

5.

Maximize healing influences outside care.

6.

Rely on sophisticated, disciplined evidence.

7.

Use all relevant capacities—waste nothing.

8.

Connect helping influences with each other.

Emphasizing these notions, he concluded by noting that “the sources of suffering are in separateness, and the remedy is in remembering that we are in this together.”

The panel discussion was moderated by Dr. Erminia Guarneri, who opened by noting that her entire medical training was oriented to the find-it-and-fix-it mentality. Yet as she gained experience, she learned from her patients that, when it comes to cardiovascular health, the illnesses of loneliness, depression, anger, and hostility are every bit as devastating as hypertension and diabetes. She said a different model of care is needed, one that puts as much stock in the importance of social and behavioral perspectives as in lab values.

Dr. Edward Wagner agreed, noting that constructive patient–provider relationships are essential to effectively providing preventive services to individuals with established chronic illnesses, as well as those without. Wagner and others suggested that the mindset and principles of primary care may provide a sound foundation for integrative health care, but to effectively move to an integrative approach, primary care will also need to change. An important element of the transformation is to recognize that, for the 40 to 50 percent of the population suffering from chronic conditions, the distinctions between prevention and treatment begin to break down since the interventions are much the same. To foster high-quality and high-efficiency primary care, the system must include high-functioning practice teams, operate according to clear protocols, use enhanced information technology, and include structured patient involve ment, said Wagner. These factors would help address the most prominent care management challenges in chronic illness care and advance toward integrative medicine.

Dr. Arnold Milstein illustrated how such approaches can be effective even in, and perhaps especially in, those settings in which the patients are sickest and poorest. He analyzed components of small medical practices (with one to two physicians, which is the type where most physicians work) and medium-sized ones (with about 60 physicians) that have effectively managed chronic diseases and controlled costs. He found that the most successful practices had certain characteristics: they worked as teams; they established close relationships with patients and provided what patients themselves perceived as personalized care; they offered some unusual services in order to address the behavioral and social elements of health care; they focused on the sickest patients in the practice and went to extraordinary effort to keep these patients out of the hospital; and they developed relationships with one or two local physicians in each specialty who practiced similarly, so that when they had to make referrals, continuity of care was maintained. He noted that each of the practices he studied could not have survived on existing fee-for-service terms and had to negotiate capitation agreements with their payers. But the result was efficient, caring experiences, delivering better outcomes at lower costs.

Dr. David Katz, Dr. Tracy Gaudet, and Dr. Mike Magee each noted that the disease-oriented approach of conventional allopathic medicine neither naturally leads to the type of clinician-patient understanding Berwick and other participants envision nor does it yield the health outcomes patients should expect. Katz noted that patients often have concerns that are in a gray zone, and the only way to effectively address them is by understanding more about the individual context of their concerns. Gaudet concurred, noting that when so much of the disease and disability among Americans is a function of personal health behavior, that the changes health professionals are asking their patients to make cannot be successful until they have deep personal significance—something she feels the current system is entirely unable to address. She said that overhauling the current health care mindset would require a physician–patient partnership, including working together to fashion a whole person medical record that embeds the key elements for planning a patient’s health future, the use of teams to manage the care process, and reoriented training to make these changes possible.

In carrying this theme forward, Magee called for the notion of a home-centered health care model—one that does not have the hospital or doctor’s office at the epicenter—as necessary to helping people achieve their full potential. He viewed the notion of home as both a geographic and a virtual place, and one in which complexity, connectivity, and consumerism become advantages. He pointed out the appeal of this notion by observing that “Americans abhor homelessness, yet have learned to accept healthlessness.” Each of the panelists emphasized the importance of a sustained program of demonstration studies for new models, especially those that include mechanisms of payment, in moving integrative medicine forward and helping overcome the current reimbursement and cultural challenges.

Science (Chapter 4)

The session on the science base highlighted the complex interplay of biology, behavior, psychosocial factors, and how the environment shapes health and disease. The keynote address for the session was delivered by Dr. Dean Ornish, who pointed out that these interactions can produce synergistic results—for good or ill—and this complexity requires a systems approach in both health care and in health sciences research that accounts for multiple variables interacting in dynamic ways. In his presentation, Ornish described examples of various food components that seem in epidemiologic studies to either protect or promote certain disease processes. However, when studied as independent factors or administered separately, they act differently, which demonstrates that these factors do not generally act independently but in complex interdependence with other dietary components.

Ornish went on to note that various studies that examine the influence of supportive relationships and comprehensive lifestyle change suggest that not only could social and behavioral interventions change the course of a disease process, but in some circumstances could stimulate regeneration and reverse disease processes, in a dose-response fashion. Stating that nurture sometimes trumps nature, Ornish discussed some relatively new findings in genomic sciences showing the potential for lifestyle changes to affect telomere length (related to aging and longevity) and gene expression.

In the panel discussion, Dr. Nancy Adler, who reviewed the social determinants of health, picked up this theme by noting that English workers in manual occupations showed a significant decrease in telomere length relative to same-age workers in non-manual fields, indicating premature aging at the cellular level. She went on to review the powerful overall impact of income and education on health status and life expectancy, including its cross-generational influence.

A specific focus on advances in genomic sciences was provided by panelist Dr. Richard Lifton, who noted that, increasingly, new, more effective treatments that are tailored to a person’s genetic profile will be available. This will greatly facilitate personalized medicine and person-centered care. Lifton noted the progress made in the 150 years since 1865 when Gregor Mendel recognized genetic factors. He offered examples of diseases such as breast cancer, Alzheimer’s, hypercholesterolemia, obesity, and many others for which contributing genetic loci have been identified in the past decade. While identification of genetic variation may fragment care in the sense that it will lead to a certain level of stratification or targeting, he said it will foster an integration of approaches to the care dynamics that are important to a given individual.

Extending the notion that it is the interactions of genes with other factors (epigenetic influences) that shape health and illness, Dr. Mitchell Gaynor reported on numerous studies indicating the influence of diet and other environmental factors on the expression of genes.

The interplay of external stressors and physiologic responses was also an issue discussed by several panelists. In his introduction to the panel discussion, moderator Dr. Bruce McEwen offered an overview of how changes in levels of physiologic mediators released in the brain, such as adrenaline and cortisol, in response to stress can produce cumulative effects over time—what he termed allostatic load. McEwen noted that psychosocial factors including stress, loneliness, and depression, trigger brain-mediated responses in neural, endocrine, and immune systems, and, in time, have adverse effects on various organ systems and disease states. People with high levels of stress can be found throughout society, observed Adler, who noted that those in lower socioeconomic strata are particularly vulnerable. McEwen and Adler also described the long-term effects of stress, adverse events, and low socioeconomic status on the health of children.

Dr. Esther Sternberg noted that as the brain responds to stress, hormones are released that can interfere with the immune response and metabolic processes and damage the cardiovascular system. On the other hand, Sternberg said, something as simple as having a support group, a wide social network, or a nurturing belief system can help people man age stress and recover from illness. She said that the road to healing also is mediated by the brain. Health-promoting activities, such as meditation, yoga, tai chi, and exercise, have biologic effects on the neuroendocrine systems. When people engage in these types of activities, the vagus nerve functions as a brake on the sympathetic nervous system, thereby increasing the power of the immune system. Also, such activities prompt release of the powerful neuroendocrine system hormones—endorphins and dopamine.

Each of the panelists emphasized the potential from scientific advances and the need for studies to accelerate progress. Yet many, including Dr. Lawrence Green who was charged with reviewing research challenges, noted the complexity of studying the involved factors. In particular, this complexity presents a significant limitation to the use of randomized clinical trials, which test one variable at a time and are not designed to evaluate multifaceted preventive approaches, such as lifestyle interventions. New, more appropriate assessment methods are under development. They range from improved effectiveness trials at the community level to studies of immune system biomarkers at the molecular level, to an array of study methods being used at the National Center for Complementary and Alternative Medicine (NCCAM)—approaches that were described by the center’s Director, Dr. Josephine Briggs. Briggs highlighted the four spheres of research conducted at NCCAM: basic sciences, translational research, efficacy studies, and effectiveness research, noting that approximately half of NCCAM’s resources are devoted to basic research, such as studies of the neuroscience of meditation and the biology of the placebo effect.

Workforce and Education (Chapter 5)

In the summit discussion on workforce and education, speakers described the implications of advances in integrative medicine for the education and training of the nation’s health professionals and researchers. They discussed strategies for changing curricula, including interdisciplinary approaches, team-based training, and expansion of core competencies in healthy living and wellness.

An often-mentioned point in this session, described by Dame Carol Black in her keynote address, is the need to expand interdisciplinary and multidisciplinary education to promote effective teamwork. Black pointed out that the only way to provide truly person-centered care is to take into account the social and economic determinants of health, which requires a very different set of provider profiles, competencies, and training. She gave, as a particular example, the importance of the relationship between work and health. Black noted that while health care providers often discuss many health behavior and environmental factors with their patients, they rarely discuss patients’ employment in a meaningful way. Yet people spend more time at work than almost any other place, and it has to represent the dominant social influence on health prospects. Even more dramatic is the condition of “worklessness,” which over the long term is a greater risk to health than many diseases. Overall, she emphasized, a rational approach to health care requires a team approach, in order to address both the growing complexity in diagnosis and treatment interventions and the similarly complex social and behavioral factors affecting health.

Dr. Elizabeth Goldblatt echoed this theme, noting that people and patients desire collaboration among their health care providers, which presumes innovative multidisciplinary educational experiences, training, and guidelines for all licensed health professionals. Yet, health practitioners typically are educated and trained in professional silos, hindering their ability to quickly transition and adapt to a team environment. Interprofessional education should begin early, particularly for physicians, to reinforce shared values and overcome the culture that rewards individual accomplishment, said Dr. Adam Perlman, who detailed the related approaches, barriers, and opportunities.

To inform the change process, demonstration projects were noted as useful in developing more effective educational models for integrative health practitioners. Dr. Mary Jo Kreitzer, who sees the necessity for disruptive innovation in both health professions education and health care delivery, suggested that community health centers be incorporated into interdisciplinary education experiences. Another approach would involve training nonphysicians to be primary care providers. Dr. Richard Cooper viewed this prospect as inevitable and critical, because of the looming shortage of primary care physicians. Expanded primary care capacity might be achieved by developing new competencies for nurse practitioners and others. Dr. Victoria Maizes suggested training programs built around core competencies in integrative health. Maizes discussed several related approaches but noted that much work is to be done in forging and getting agreement on a competency-based curriculum of the sort needed.

Underscoring the need for a new look at competencies and curriculum was the fact that, regardless of professional and specialty mix, health care practitioners today are not able to overcome some of the most important factors in health and disease, including the socioeconomic factors raised by Black. In many respects, Cooper said, poverty constitutes the greatest of all the challenges facing the health care system. In fact, approximately 17 percent of all Americans and 21 percent of their children live in poverty, ranking the United States with the third highest rates of poverty overall and fourth highest rates of poverty for children among OECD² nations (OECD, 2009).

Sir Cyril Chantler addressed the question of legal and regulatory implications inherent in a move toward integrative medicine. Chantler noted the need to ensure an adequate evidence base as a precondition for the integrative practice and its oversight. But he also noted the need for standards appropriately tailored to the individual issue at hand, with patient safety the top priority. However, evaluation needs to go beyond this to address questions of benefit and cost-effectiveness. One of the challenges is to ensure that the consideration of benefit includes individual patient values. In the matter of credentialing, Chantler noted that standards for professional competence should be clear and consistent, that outcomes should be carefully recorded and audited, and that teamwork capacity should be an essential element.

In a comment that reflected the overall spirit of the discussion and the need for action, Chantler acknowledged the importance of the axiom primum non nocere, “first do no harm,” but also added another, deinde adjuvare, “next do some good.”

Economics and Policy (Chapter 6)

The keynote address for the session on economic and policy issues was delivered by Senator Tom Harkin who shared his optimism about meaningful health reform by referring to President Obama’s recent remarks before a joint session of Congress, in which he predicted that Congress would pass a comprehensive health reform measure in 2009 and that the centerpiece of the reform would be a new emphasis on prevention and wellness. Harkin noted that, unlike previous occasions, public sentiment is now clearly that the health care system is substantially dysfunctional and in need of dramatic change. He called for a system that emphasizes care coordination and continuity, patient-centeredness, holis tic approaches, and wellness. Such an integrative approach, he said, would take advantage of the very best scientifically based practices, whether conventional or alternative. It would focus on the twin goals of improving outcomes and reducing costs.

In the following panel discussion, Dr. Kenneth Thorpe reiterated that changes outside the health system (e.g., environmental and food policy) can have a profound effect on health, and that there is an opportunity for reforms in these areas to be included in an administration-wide discussion of health reform. For every dollar spent on medical costs for treating chronic diseases, many of which are preventable, he suggested, another $4 is lost through decreased productivity. He acknowledged the difficulty that small physician practices have in providing services such as care coordination, primary prevention, and community outreach, and supported development of community health teams that would include nurse practitioners, social workers, and behavioral health workers to collaborate with these practices to make these services available.

Dr. Janet Kahn also suggested greater coordination of health-promoting activities across government agencies, including agencies outside of the Department of Health and Human Services, as part of the reform process. In discussing the political and policy realities, panelists cautioned that health reform, especially reform emphasizing integrative concepts, is far from a certainty. As a tactical matter, Tom Donohue warned against pointing fingers at other sectors and advised that advocates unite around commonly held values.

Dr. Reed Tuckson emphasized that health insurance companies have agendas and missions that are well aligned with the summit’s goals, and noted that his own company, UnitedHealth Group, views itself as “a health and well-being company.” His emphasis was on the need for evidence on workable models that could be used to support changes in financing. When thinking about integrative medicine, he asked for clarity in how different members of the comprehensive care team are to be trained, credentialed, evaluated, coordinated, coded, and reimbursed, and how redundancy would be minimized and efficiency improved.

Donohue said that businesses today are supportive of health system change. For insurers and the business community alike, the dominant concern is rising health care costs. Donohue and William George both viewed the business community as strong participants in reforming the health system, not only because of their traditional insurance role, but also because of their successes with employee wellness programs. George noted that the goal for employers that emphasize wellness is not achieving the lowest cost for employee health benefits; it is to have 100 percent of employees fully present on the job every day—in other words, improved productivity. The starting point for that productivity is a corporate culture where health is honored and enjoyed.

Examples of the ways successful programs have not only improved employee health but also demonstrated return on investment to employers were described by Dr. Kenneth Pelletier. He reported on research that identified 153 clinical and cost outcome studies of worksite integrative health approaches, all of which demonstrated net benefits with respect to short- and long-term disability, absenteeism, personnel retention, presenteeism, and performance. Pelletier noted that the studies he reviewed reflected returns on investment ranging from 3.5 to 4.9:1. He suggested approaches that might be used to further evaluate the potential economic returns from integrative programs.

Concluding Comments (Chapter 7)

The final session of the summit was devoted to an open review of key points of the summit discussions, including a panel conversation among the moderators of the five previous summit sessions, followed by closing comments from Fineberg and Snyderman. In the panel discussion, participants noted the clear emphasis throughout the summit on reorientation of care to perspectives that emphasized prevention, were person centered and life span long, accommodated multidisciplinary team engagement, and tended to the social, home, and relationship environments so important in influencing individual and population health.

Participants also identified considerations of particular importance moving forward. Johns, for example, noted that a challenge was to avoid piling an entirely new set of practitioner tools onto existing practice patterns. Rather, in integrative health an entirely new orientation is needed, including the involvement of an “optimizer”—human and/or electronic—devoted to ensuring that the right intervention is provided at the right time and the most appropriate place. Guarneri commented that the practitioner’s toolbox has to be equipped with much more than drugs and devices. Instead, it needs to be designed as a community kit for use in a care model drawing on multidisciplinary teams. However, considerable work would need to be done to bring credentialing and financial incentives into alignment with the vision.

In addressing the issue of involving multiple disciplines, McEwen remarked on the impressive promise of advancing science, if it can break free from the tendency toward specialization and reductionism, but he cautioned that engaging truly interdisciplinary perspectives and activities is very challenging. The signals must be strong from field leaders, in training programs, and from funding sources. Goldblatt again stated the importance of beginning very early in the professional training process with priorities, emphases, and skills directed to wellness and to understanding the range of factors in play for the whole patient, not just the physiologic correlates of the presenting symptom. She noted that if people are educated in silos, they will practice in silos, and that style of practice in increasingly untenable.

Tunis reminded participants that the United States is faced with a once-in-a-generation opportunity for major political and social change on behalf of better health care. He noted that the economic challenges may in fact be working to counter a culture of greed and shift to greater resonance with the values of integrative medicine—internal reflection, connectedness, and community support. He also cautioned that sustaining the “shared sympathy” of the discussions would be a challenge, but it was very important, given the natural inclination in resource-related discussions to point fingers and place blame across sectors. Finally, he predicted that integrative medicine may turn out to be the most successful approach to reforming the nation’s health system.

In their concluding remarks, Snyderman, chair of the summit planning committee, and Fineberg, president of the IOM, both thanked all of the participants for their time, their active engagement, and their energy and enthusiasm throughout the summit. Snyderman and Fineberg said the event was far bigger and far more important than the organizers could have anticipated when they began the initiative more than a year earlier.

Returning to the Rorschach blot that Fineberg discussed in his opening remarks, Snyderman reiterated that everyone had arrived at the meeting with some image of integrative medicine. Those images were probably different in virtually every mind, and while the summit had not led to a precise and universally accepted view of integrative health care—nor was that the intention—it had clearly led to much greater understanding, to identification of common elements, and to appreciation that at its center is an individual with unique requirements for maintaining health, preventing disease, and health care services. Snyderman said that the unique individual is each of us over the course of our lifetimes; it is our friends and family members; and it is every one of the nation’s children, with their different socioeconomic backgrounds and opportunities, their different racial and ethnic identities, their different family dynamics, and their different futures.

Snyderman also noted that Fineberg was wise to ask people, near the end of the plenary, what they had learned, what for them was different. He concluded by saying that “to some degree all of our minds have been changed, unalterably. We are different people, capable of taking different actions. Much of what comes out of the summit will depend on the spontaneous actions and the creativity of every person in the audience. We all can play a role in keeping this movement going forward.”