- Integrating complementary and alternative medicine into academic medical centers: Experience and perceptions of nine leading centers in North America
We identified ten leading North American integrative medical centers. Visits took place during 2002–2003 and involved a total of nine sites. We could not visit the tenth site identified due to time constraints. Site visits provided a snapshot of the top integrative academic health science centers in North America. The authors learned how each started their program, how it evolved, what worked, and what did not. The earliest integrative medicine program visited opened in 1991, while the rest launched in the intervening decade. A common reason for the initiation of the CAM programs visited was an underlying interest in the center, catalyzed by a directed donation or endowment fund (usually $1–10 M USD). Each program stressed the importance of having a well-respected person (usually an MD) who could "champion" the initiative. The findings can generally be divided into four domains: 1) clinical programs; 2) research programs; 3) educational programs; and 4) administrative structure.
The programs visited varied from the largest provider of integrative care in the US to programs with accessory virtual clinics or programs with clinics that were planned, but did not yet exist. On-site CAM services included Traditional Chinese Medicine (TCM) as a whole system, acupuncture, TCM supplements, chiropractic, massage, aromatherapy, homeopathy, herbal medicine, mind-body and biofeedback. Conventional Western medical care was always offered on-site at the same facility, with services such as family medicine, internal medicine, psychiatry, physiotherapy, nutrition, etc., as well as conventional medical trainees in most sites.
Patients attending academic integrative medicine programs presented with a broad range of complaints including: menopausal symptom management, chronic fatigue, fibromyalgia, depression, irritable bowel syndrome, chronic pain, emotional/mental health, infertility, asthma, and symptoms related to cancer/cancer therapy. Providers at the sites agreed that patients came to the clinic because the program assessed the "whole person", rather than for a second opinion on their diagnosis. While all programs insisted patients see a team physician as part of their assessment (if they were not already under the care of a family physician), the physician was not necessarily the gatekeeper (i.e., did not have to see the patient before the other providers, nor was physician approval to see a particular CAM provider necessary in most centers). Experience has taught the practitioners that "less is more", e.g., having more CAM providers involved in each patients' care was expensive and could leave a patient feeling confused. Instead, the goal was to have a clear and simple care plan, and an opportunity to develop a meaningful relationship with one care provider. Outcomes were reviewed approximately every three months and if the patient was not making progress or achieving their goals, the treatment plan was reviewed.
The different programs visited appeared to interpret the concept of practicing "evidence-based medicine" differently. Given the frequent gaps in the evidence with respect to CAM, a common approach was that if there is evidence that a product or therapy does not work or is harmful, then it was not be used. However, if there was simply inadequate evidence to prove efficacy, many programs were willing to offer it, if only so that it could be studied. One person described their approach as asking: "Does it make sense? Is it reasonably priced?" Decisions were made based on the answers to these questions in the absence of information about efficacy.
Program choices regarding which CAM services to provide at each center were in part based on regulatory status, partly on patient demand, and also on the ability to find the right individuals to become part of the team. The goal was not to train the MD in all modalities of CAM, but to work with CAM experts so that all team members could learn when and how to refer appropriately. When choosing CAM practitioners for the clinic, the sites emphasized the importance of carefully assessing the individuals applying. Several cites voiced it was critical to involve CAM providers who were certified in their own field and who stayed within their scopes of practice in order to minimize liability concerns. In most clinics, all CAM providers carried liability insurance that they paid for themselves (up to $3 M USD). Program directors emphasized that CAM providers who had "cross-training" (i.e., with conventional medical professions) were preferred. The CAM practitioner was advised that for the clinic's purpose, scope of practice may be limited compared to what they could do outside of the program.
As CAM was not covered by many private or public insurers, the programs had to create strategies to overcome potential inequities based on a fee-for-service system. Some programs billed every patient, irrespective of insurance status, leaving it up to the individual to see if their costs will be reimbursed. Others had subsidy programs or reduced fees for patients who could not afford care. Very few programs were profitable, yet they agreed "no margin, no mission," suggesting that above all, it was necessary to stay in business if one wished to help patients.
In almost all circumstances the clinics held a multidisciplinary case conference about patients, the content of which has evolved over time. The intent of this conference was usually to broaden awareness of each team member's knowledge and scope of practice, and to coordinate patient care plans. In most instances, more established programs spent less time on this activity, and in some it was eliminated because it was too expensive or no longer needed (i.e., collaborative relationship and trust had been established and providers were comfortable with referral).
Programs have generally discovered that research was a critical element to success. With evidence, they were better able to convince skeptical colleagues about the value of their approach. Some sites grew around a foundation of research; others were adding it as time passed. One program advised choosing research areas based on where team members have passion, interest and expertise. Another program did a survey of University faculty members and found 400 members who were interested in CAM research. From this, their strategy was to build the center with people from within, thus building confidence and acceptance by engaging local senior researchers. The key was to find internal, open-minded, rigorous clinical and basic science researchers. Another team acknowledged that most of their research actually happened off-site, e.g., with collaborators in nursing, pharmacy, internal medicine and psychiatry.
Different programs had different research foci. One was looking at phase I-III trials in herbal medicine, including basic sciences questions such as mechanism of action, or examination of the immunological effects of whole formula vs. single "active" ingredient in vitro. In another center, every client was asked to participate in outcomes research, with measures taken at baseline, six months, and 12 months. The measures were used to try to capture self-reported health concerns, client satisfaction, social support, and pain. The research nurse would meet with all patients when they entered the program, and discuss their goals and motivation for coming to the program. She would contact them throughout the care process, and assessed the six month measures (How are you feeling now? What do you attribute that to?).
The scope of the educational programs varies from site to site. Most established centers had an education director, and had set up a variety of educational opportunities. These included lectures to and electives for medical students, rotations for internal medicine residents, and a survey course where medical students learn about and experience CAM therapies. The students were required to do research during rotations, usually a literature search and presentation at rounds. At one site, 25 community-based CAM providers donated their time to run workshops. Another center started a fellowship program in 1999, and at the time of our visit, had an NIH training grant for six fellows. They also held an annual continuing medical education (CME) event and prepared online cases for CME credit. A different center had an exchange elective whereby medical students met with students from the American College of Traditional Chinese Medicine to teach each other about physical examination and diagnosis, and "share the process of becoming a healer" in both systems (students teaching students).
We queried participating sites on the operations of their integrative program as well as the critical factors to the success/failure regarding the team, its resources, structure and process (see Table 2).
The administrative structure varied between programs. Often team members reported to research/education/clinical directors, who reported to a program director, who, in turn, reported to the program advisory board and, in centers affiliated with medical schools, the Dean of Medicine. Advisory board membership was usually chosen to represent a diversity of perspectives as well as opinion leaders across different fields to maximize "buy-in". Typically the advisory board met once a year, while the executive committee (or the directors within the program) met every two weeks to every two months depending on the number of issues to discuss. All the staff of the center might meet quarterly for one hour (often at lunchtime) for strategic updates from the executive committee.
Duties of the clinic director were to oversee such things as credentialing, malpractice issues, pharmacy and therapeutics committee, and clinical care delivery. The research director oversaw all research associated with the program and was often responsible for obtaining research funding. The education director would typically oversee trainee rotations, fellowship programs, CME events, and be a liaison to the medical school. Most program directors were responsible for overseeing clinic administration, such as finances, human resources, payroll, contracts, and the day-to-day operations of the clinic etc. Some clinics also had a fundraising committee. The key themes for the administration of a successful integration program are listed in Table 2.
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