Advice for the National Center of Complementary and Alternative Medicine

The Integrator Blog, a site dedicated to business news and trends in integrative medicine and complementary medicine, gives advice to the new Director of the National Center for Complementary and Alternative Medicine. The Integrator Blog has its own style, but also its advice lays down a challenge that makes sense to me: if you really want to understand complementary, alternative, and integrative medicine, understand it experientially. Even if you have the finest research credentials and clinical experience on the globe, you cannot understand something like, for example, meditation, merely as a fly on the wall (a scientist-fly, that is).

There is an old story about the ladle trying to taste the pudding.

It is much more difficult to be dismissive if one has their own experience. Of course, we need to question our experience, just as Descartes questioned his. (Of course, Descartes was the one who separated mind and body, questioning whether he really had either, and setting up centuries of mind-body dualism. Kids, don't try this at home.)

But in many ways, "complementary, alternative, and integrative medicine" is a quadruple misnomer: it isn't necessarily complementary, alternative, or integrative -- though these words, for now, help anchor various philosophical platforms; and it isn't necessarily even "medicine" (at least not in the 20th-century, legal and technological sense; though it may be if one thinks in the metaphor and archetype of the Medicine Buddha).

That would make a great statement for a final exam, followed by: "discuss." For now, suffice it to say that "healing" is a much broader idea than "biomedicine" (see A Fixed Star in Health Care Reform: The Emerging Paradigm of Holistic Healing) and that the notion of 'medical pluralism' encompasses a much larger path than certain technological approaches to health care that we sometimes denote through various labels such as 'reductionistic,' 'Western' and so on (see Healing at the Borderland of Medicine and Religion for a longer discussion). So The Integrator wisely suggests seeing some of these therapies 'up close and in person' before rendering judgment. All of which is to say to add other forms of empirical evidence to the usual 'literature search.' After all, the evidence base of being human is quite broad.

But first, a quiz:

"Nick'em" stands for:

1. An ad for a razor company whose shaving equipment is guaranteed not to harm the chin;

2. The name of an Australian football team.

3. A derivation of "En-Cam," the National Center for Complementary and Alternative Medicine at the National Institutes of Health (NCCAM).

4. An English soccer player.

If you answered "3," you will enjoy The Integrator's letter. John Weeks, who has given permission to reprint his letter in the Complementary and Alternative Medicine Law Blog writes:
Friday, 25 January, 2008

Josephine 'Josie' P. Briggs, MD, Director Designee NIH National Center for Complementary and Alternative Medicine Bethesda, Maryland

Dear Dr. Briggs:

Oops, they did it again.

Honestly, those were my first, formed thoughts on reading in the NIH NCCAM e-newsletter about your appointment as the new NCCAM director.

I am not sure Britney Spears and the NIH have ever been in the same sentence before. But there does appear to be something a little loco going on here. Your indulgence, please. Your predecessor, Stephen Straus, MD, also had no experience in complementary and alternative medicine. He told the New York Times during his tenure that he had no plans to experiment. I always thought that an odd waste of human imagination. This is not cancer, or renal failure we're typically talking about. These are therapies and approaches which many view as particularly valuable for creating health and vitality - often altering the course of disease, or a person's experience of disease, in doing so. Why spend 7 years as an "investigator" and never personally investigate?

Now, a decade later, the NIH has done it again. Director Zerhouni appointed you, despite the fact that you too have no visible professional experience in the field that you were selected to lead. Of your 125 publications, none appear to touch on the kinds of interventions which will be on your desk at your new job.

Let me provide some perspective, Dr. Briggs, so you might understand why this is felt as a shock. Back in 1997, you were a candidate to become the head of the Division of Kidney, Urologic, and Hematologic Diseases in the National Institute of Diabetes and Digestive and Kidney Diseases. This was your field. You were appointed. You headed the division for nearly a decade.

Now imagine you had not been successful in your application. Curious about who had been selected, you learned that the NIH had appointed, instead of you, a dermatologist. What? A dermatologist?

Imagine now that the position came open a couple years later. You applied again. Finally, a chance to have an experienced expert in our field running the Division! Then came the announcement from the NIH: "It is with great pleasure that I announce today that the new director of the Division of Kidney, Urologic, and Hematologic Diseases is an individual with exceptional research portfolio, who is a podiatrist."

I assume you have passion for your field, as I know some top quality candidates for the NCCAM directorship, who were passed over for you, have for complementary and integrative medicine. Such passion typically energizes the best work of any kind. I know that passion moves thousands of professionals who are devoting their working lives to advancing the usefulness to human health of the fields and therapies NCCAM is charged to explore. It appears that from the perspective of NIH leadership, such experience and passion, when it comes to finding a director, makes one an untouchable.

Perhaps you can explain why the NIH would choose a novice, for the second time - it's officially 2 for 2 on this count - to run one of its domains? The answers that come to mind, and which I have heard from colleagues in the last 24 hours, range from fear to ignorance to suppression.

Most note, however, that they wish to give you time, and the benefit of the doubt.

After the error of omission, some steps to limit adverse outcomes

I agree, though confess to finding it a challenge. This is not now any judgment of you. You did not create the culture that appointed you. I hope you will acknowledge that the NIH's decision was a significant error of omission. The good news is that such errors, by definition, may or may not lead to adverse outcomes.(1) I suggest that you consider the following approaches for warding off adverse effects of this NIH error.

Subjective

Go get yourself some experience of complementary, alternative and integrative practices. You have excellent resources near by. Go to the center run by Brian Berman, MD, at the University of Maryland. Get an acupuncture treatment from Berman or from Lixing Lao, LAc, MD (China). Engage Berman. Get to know the breadth of the clinical understanding he and other integrative medical doctors bring to patients.

Then go visit Bob Duggan and his team and students not far away at Tai Sophia Institute. Spend some time at their teaching clinic. Tai Sophia sees itself as an educational institution for the wellness revolution. Learn how these acupuncturists and herbalists and applied healing arts specialists in Tai Sophia's programs describe their potential value to human health.

Come back to D.C. to the Potomac Massage Therapy Institute. Meet with its director Demara Stamler, CMT and her staff. Get a massage. Consider how your leadership can support the grossly underfunded research efforts of the CAM disciplines. Stop over at Georgetown University School of Medicine, with which PMTI has partnered. Meet with Adi Haramati, PhD, and have his faculty, or his colleague at the Center for Mind-Body Medicine James Gordon, MD, offer you the experience of guided imagery and of other mind-body approaches.

Ask your Beltway neighbors David O'Bryon with the Association of Chiropractic Colleges to set you up to get a chiropractic adjustment; and Karen Howard, with the Association of Accredited Naturopathic Medical Colleges, to help you find a naturopathic physician to give you the experience of whole-person naturopathic medical care.

Take advantage of these local resources. Consider it your basic training. Experientially equip yourself to be able to think with clarity and imagination about NCCAM's opportunities.

Objective

Examine the research portfolio you have inherited. You will discover that just 0.6% of NCCAM funds in 2006 were dedicated to examining the effectiveness and cost-effectiveness of these interventions. You may not yet know why this imbalance is particularly unfortunate. Consider: Unlike most of what NIH examines, these therapies and practitioners are already in use, by millions of the citizens you are there to serve. Why not look at their experience rather than reducing it to something they wouldn't buy before you measure it? Advance the new health services initiative.

Now examine the poverty in which "whole systems" and "whole practice" approaches languish at the NCCAM. Despite being in the NCCAM plan, and despite the advocacy of such methodologies by research leaders in every one of the disciplines which you are charged to explore, these methods have been fed mere crumbs. Make a whole systems/practice initiative a priority.

Speaking of the disciplines: Note that NCCAM is presently wildly out of compliance with the letter and intent of the enabling legislation passed by Congress regarding the make-up of the National Advisory Council for Complementary and Alternative Medicine. The law says 50% plus of the members should be licensed in the fields you are charged to explore. The present NACCAM is at just 25%. Take a look at the resumes of excellent candidates that have already been submitted to help bring you to compliance. Consort with those less known to you. Find the people on the NCCAM staff who have grown to understand these CAM fields and are learning to articulate more appropriate questions. Bring them in close. Learn from them.

Now, big picture, notice that the Nation that you are serving is in a midst of a major debate over health reform. Much of it is about cost. Some of the suggestions for resolving the crisis are also about approach, urging more health promoting and preventive strategies. Allow yourself to consider that these untouchables you have been charged to lead may - if you ask the right questions - have their use in helping to resolve these problems.

I venture that if you follow what you learn from these encounters, your Assessment & Plan will go a long way toward correcting the error of omission that your appointment represents.

Perspective of a conventional academic researcher

I spoke with a conventional academic medicine colleague and researcher yesterday who is a close NCCAM watcher. He said he was "flabbergasted - not in a positive way" by your appointment. His gut feeling was that "the appointment makes it very clear that the NIH wants to bury NCCAM." He wondered why you took the job, given your career path. Did you just want to be on the NIH director's Council? Is it, for you, merely a step in dirty water, a post in Siberia on a career path which you hope will veer back into other zones more prestigious in your view - a plum position in Moscow? - as soon as possible?

My colleague told me he believes that, with all of the momentum in recent years, and the increased interest among employers and consumers, the field of integrative medicine is going to keep growing. The question on the table, he believes, is "whether NCCAM will provide leadership or become irrelevant." He opined that, at best, you, Dr. Briggs, are on "a steep learning curve to not be patronizing" to those who are 10-30 years deeply connected to the potential for human health that rests in complementary, alternative and integrative approaches and practitioners.

Your honeymoon, as incoming director, has begun. Most in these fields have an almost unhealthy willingness to allow the best to come out of a person or a situation. A leading chiropractic researcher just sent me a note with the same wish, to give you time. Please put yourself on a fast track to experience, and begin to understand, the whole of what your new environment has presented you. If you do, you will find yourself at the very front lines of clinical care thinking that may be particularly useful as we try to get our hands on the multi-factorial chronic diseases. You will be surrounded by many wonderful, savvy, intelligent, free-thinking, and problem-solving souls. Not a bad world to inhabit, if you give it a chance.

Good luck with your new job.

In health,

John Weeks, Publisher-Editor Integrator Blog News & Reports www.theintegratorblog.com

(1) Definition accessed by click on the Joint Commission on Accreditation of Health Care Organizations.

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NIH Biography for Josephine Briggs, MD

On January 24, 2008, NIH Director, Elias A. Zerhouni, M.D., named Josephine P. Briggs, M.D., to be the director of the National Center for Complementary and Alternative Medicine (NCCAM). An accomplished researcher and physician, Dr. Briggs brings a focus on translational research to the study of complementary and alternative medicine (CAM) to help build a fuller understanding of the usefulness and safety of CAM practices that nearly two-thirds of the American public uses.

Dr. Briggs received her A.B. cum laude in biology from Harvard-Radcliffe College and her M.D. from Harvard Medical School. She completed her residency training in internal medicine and nephrology at the Mount Sinai School of Medicine, followed by a research fellowship in physiology at Yale School of Medicine. She was a professor of internal medicine and physiology at the University of Michigan from 1993 to 1997. From 1997 to 2006 she was director of the Division of Kidney, Urologic, and Hematologic Diseases in the National Institute of Diabetes and Digestive and Kidney Diseases. For the last year and a half she has been senior scientific officer at the Howard Hughes Medical Institute.

Dr. Briggs has published more than 125 research articles and is on the editorial boards of numerous journals. She is an elected member of the American Association of Physicians and a fellow of the American Association for the Advancement of Science. She is also a recipient of the Volhard Prize of the German Nephrological Society. Her research interests include the renin-angiotensin system, diabetic nephropathy and the effect of antioxidants in kidney disease.
One more 'thought:' I like the writer who said that the history of Western intellectual thought -- and possibly of medicine -- would have been completely different if Descartes had simply written, "I love, therefore I am." How do I know that I am? Because I love, not because I think.

Last night I heard a lecture by someone who holds a PhD in psychology and a degree in naturopathic medicine. He practices psychology in one room and naturopathic medicine in another. Why? Because, he said, we have to separate mind and body. Legally, he feels, when he treats "the mind" he cannot touch "the body," for fear of a lawsuit. So when he wears one professional hat he leaves the other one in the other room. All of the credentials on the wall of one room say Mind Healer and those in the other room say Body Healer. He feels our current health care system, and the laws that support it, have forced him into repeating the 'original sin' of Cartesian dualism.

It would have been nice to sit in the armchair opposite Descartes and ask: 'Okay, so I think therefore I am, but what is "I"? What is "am"? Sorry, Mr. D, but the 'therefore' is just too easy."

In the meanwhile, read the Integrator Blog. He doesn't have Descartes in the chair, but engages NCCAM in the kind of dialogue a 'CAM' or integrative medicine practitioner might have had with the French philosopher.
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The Law Offices of Michael H. Cohen offers corporate legal services, litigation consultation, and expertise in health law with a unique focus on holistic, alternative, complementary, and integrative medical therapies. The law firm represents medical doctors, allied health professionals (from psychologists to nurses and dentists) and other clinicians (from chiropractors to naturopathic physicians, massage therapists, and acupuncturists), entrepreneurs, hospitals, and educational organizations, health care institutions, and individuals and corporations.

Michael H. Cohen is Principal in Law Offices of Michael H. Cohen and also President of The Institute for Integrative and Energy Medicine, a nonprofit organization exploring legal, regulatory, ethical, and health policy issues in the judicious integration of complementary and alternative medical therapies (such as acupuncture and traditional oriental medicine, chiropractic, naturopathic medicine, homeopathy, massage therapy, energy healing, and herbal medicine) and conventional clinical care. Michael H. Cohen is author of books on health care law, regulation, ethics and policy dealing with complementary, alternative and integrative medicine, including Healing at the Borderland of Medicine and Religion, Complementary and Alternative Medicine: Legal Boundaries and Regulatory Perspectives (1998), Beyond Complementary Medicine: Legal and Ethical Perspectives on Health Care and Human Evolution (2000), and Future Medicine: Ethical Dilemmas, Regulatory Challenges, and Therapeutic Pathways to Health Care and Healing in Human Transformation (2003).
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Health care and corporate lawyer Michael H. Cohen has been admitted to the Bar of California, Massachusetts, New York, and Washington D.C. In addition to qualifying as a U.S. attorney, he has been admitted and to the Bar of England and Wales as a Solicitor (non-practicing). For more information regarding the law practice of attorney Michael H. Cohen, see the FAQs for the Law Offices of Michael H. Cohen. Thank you for visiting the Complementary and Alternative Medicine Law Blog.
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