Interview

The Academic Consortium for Complementary and Alternative Health Care (ACCAHC): Developing Collaboration Among CAM Professions, Forging Integration with Conventional Health Professions—an Interview with John Weeks

Daniel Redwood, DC

 

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Topics in Integrative Health Care 2012, Vol. 3(2)   ID: 3.2002



Published on
June 28, 2012
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A previous version of this article was published in Health Insights Today, a publication of Cleveland Chiropractic College-Kansas City, and is reprinted with permission.

Abstract

The Academic Consortium for Complementary and Alternative Health Care (ACCAHC) represents all the licensed professions defined as complementary and alternative medicine (CAM) by the U.S. National Institutes of Health—chiropractic, naturopathic medicine, acupuncture and Oriental medicine, and massage therapy—along with a second membership category for traditional world medicines and emerging professions. The organization serves the dual role of enabling its member professions to understand and collaborate with one another, while also allowing CAM to speak with a unified voice in its relations with conventional biomedicine and government agencies.

ACCAHC has multidisciplinary working groups on education, research, and clinical care, with a focus on integrative care central to the organization’s mission. Recent projects include completing a competencies document for optimal practice in an integrative environment and participating in the Institute of Medicine’s Global Forum on Innovation in Health Professional Education and the Pain Action Alliance to Implement a National Strategy.

John Weeks, the executive director of the Academic Consortium for Complementary and Alternative Health Care (ACCAHC), has been a writer, organizer, executive and consultant in the field of integrated health care for over two decades. Weeks co-founded ACCAHC, which is the only organization in the United States with full participation of the councils of colleges and accrediting agencies from all the licensed professions defined as complementary and alternative medicine (CAM) by the National Institutes of Health—chiropractic, naturopathic medicine, acupuncture and Oriental medicine, and massage therapy. As such, ACCAHC comes closer than any other group to being the official voice of CAM in the United States.

In this interview with Daniel Redwood, DC, John Weeks discusses current developments in cross-disciplinary collaboration and integration, including the U.S. Institute of Medicine’s Global Forum on Innovation in Health Professional Education, where ACCAHC is the sole representative of the natural health care professions, and Collaboration Across Borders, an international project focused on interprofessional education and care (IPE/C), where ACCAHC again represents the interests and perspectives of the licensed professions defined by the NIH as complementary and alternative.

Weeks has helped organize some of the most significant multidisciplinary collaborative forums among disciplines and stakeholders, including: the Clinician Work Group on the Integration of CAM for the Office of the Insurance Commissioner for the State of Washington (1997-1999); three Integrative Medicine Industry Leadership Summits which involved leaders of all healthcare stakeholders (2000-2002); the National Policy Dialogue to Advance Integrated Care: Creating Common Ground (2001); the Integrated Healthcare Policy Consortium, for which he served on the steering committee (2002-2008); Collaboration for Healthcare Renewal Foundation (2001-2004); and organizing and directing the National Education Dialogue (NED) to Advance Integrated Healthcare: Creating Common Ground (2004-2006).

Weeks also publishes The Integrator Blog, which has as its mission linking leaders of integrative healthcare organizations and businesses. His writing and research on the business of integration has been widely referenced and utilized, in such media as Newsweek, Modern Healthcare, Hospitals and Health Networks, New York Times, Boston Globe, and in various foundational works in the evolving field such as the White House Commission on Complementary and Alternative Medicine Policy (2002), the Bravewell Collaborative’s Clohesy Report (2003) and the Institute of Medicine’s CAM investigation (2005). 

In 1996, the National Institutes of Health contracted with Weeks to write a paper on the coverage issues in integration. He has consulted and presented widely on integration strategies for numerous hospitals, complementary healthcare educational institutions and professional associations, managed care firms and conventional academic health centers.


What is the mission of the Academic Consortium for Complementary and Alternative Health Care?


We defined a mission and vision formally in 2005. To combine the vision and mission, I would say that we seek to enhance patient care through fostering more mutual understanding among the health care disciplines.

What organizations form the core membership of ACCAHC?


We chose to form it around the five more significant disciplines that had been lumped together as complementary and alternative medicine, or CAM. That’s really in the Washington State context, because one of the five, midwifery, is not thought of as CAM nationally. The idea was to identify which of the disciplines have engaged enough of the self-regulatory and regulatory work to have not only set up good schools and developed an accrediting agency, but to have secured for that agency recognition by the U.S. Department of Education.

The core disciplines with which we’re involved, principally working with their academics, are chiropractic, naturopathic medicine, acupuncture and Oriental medicine, massage therapy and certified professional midwives (the homebirth-focused direct entry midwives). Those five core disciplines are the center of our work.

Our thinking was that too many discussions about the integration of so-called CAM with conventional medicine were unnecessarily obscured by people saying, “Well look, there are 260 different therapies or 1200 therapies, depending on whatever list you’re looking at.” We replied that there’s a much simpler way to look at this, which is to approach integration via those disciplines that have engaged this level of work in, frankly, getting their papers in order so as to participate in the system.

Opening the Door, Welcoming New Arrivals


There’s a caveat here, in that once we set that as our core bar—focusing on the councils of schools and the accrediting agencies of those fields rather than the professional associations, because we’re an academic consortium—we realized that we wanted to break a nasty pattern in health care history and most other history, which is that once you’re inside the door, you slam it on those who are outside. 

So you built into the heart of ACCAHC’s process an expectation of change, growth and evolution.


Yes. We realized that as recently as 1985, only one of our five disciplines, chiropractic, would have been able to meet our standards. All the other recognitions of the accrediting bodies had happened since that time. So we decided to set up a category for emerging professions that have engaged in processes of self-regulation and regulation. We have a separate category for those organizations, which must go through an application process to join. They as a group together have one nominee to ACCAHC Board of Directors, whereas each of the agencies for each of the other five fields automatically nominates one person to the board.

A core discipline has a chance to have 3 nominees to the board if its council of colleges, accrediting body and certifying organization all are members—as is the case with chiropractic, naturopathic medicine and acupuncture and Oriental medicine. The structure is complex. We wanted to achieve balance and keep a door open.
Our emerging professions members now include the International Association of Yoga Therapists, which convened a meeting of their schools for the first time, with our tutelage, and is setting education standards in yoga therapy with our support. There’s a homeopathic accrediting body, the Accreditation Commission for Homeopathic Education in North America, that’s trying to get itself recognized by the Department of Education. There is also a homeopathic certifying organization that is applying right now. The National Ayurvedic Medicine Association, a current member, is working on educational standards for Ayurvedic medicine. Those are the combined traditional world medicines and emerging professions members that we have.

Internal Work, External Outreach


It seems to me that ACCAHC has both an internally-focused set of projects, where CAM professions learn to better understand and collaborate with one another, and an externally-focused set of projects, where CAM professions as a group interact with conventional biomedicine. Let’s start with the internally-focused work. ACCAHC has working groups on
education, clinical care, research, and one in the works on health policy. How do these working groups work and how is it working out?

The working groups are truly the engine of much of our activity. We set them up with a great deal of consideration and developed a policy of maintaining balance amongst our disciplines. Each working group has co-chairs representing more than one discipline. The working groups, on their own, decide which projects they wish to engage, as long as they’re aligned with our mission, with the intention to be producing work products that will be useful across our fields.

Regarding your question about internal and external focus, these working groups are working both internally and externally. They were originally formed with an external purpose. In 2004, I was the director of the National Education Dialogue to Advance Integrated Health Care, which was a project of the Integrated Healthcare Policy Consortium. Through my Integrator Blog work, I was connected with the leadership of the so-called CAM disciplines and the people who were leading integrative medical education in conventional academic health centers.

We decided that it would be good to have a meeting of educators in these two areas. Adi Haramati from Georgetown, who runs the integrative medicine program there, has truly been the leader on the conventional academic side in forming bridges with the licensed natural health care disciplines and their educators. He said we could convene at Georgetown. Then he made the very practical suggestion that the dialogue would work best if all of the non-conventional groups got together and figured out in advance what their shared issues were, and then together brought those to the table. Otherwise, it could have been pretty chaotic.

So ACCAHC was actually formed with the charge of identifying shared issues among the CAM disciplines relative to conventional academic medicine and relative to the integration process. We engaged in that dialogue, which at the time was one of the broadest interprofessional, horizontal dialogues that anyone in U.S. health care could point to.

Building Horizontal, Non-Hierarchical Relationships


Explain what you mean by “horizontal.”


Nobody from a particular discipline was running it. There were 25 people on a steering committee, and we ended up having 75 people attending from 11 different disciplines. At the core of it were the educators from the Consortium of Academic Health Centers for Integrative Medicine and what we organized (with Pamela Snider in the lead as the first executive director) as ACCAHC.

Once the ACCAHC disciplines were in the same room together, everybody realized that, for a variety of reasons, there is real value in continuing to be in the room together, above and beyond the dialogue with the MD academics. That, in turn, led to the decision to formally incorporate, create by-laws, and move forward as an ongoing charitable entity around the mission and vision we’d set. We’ve always known that part of our work is to figure out what the synergies are in working together internally, what the values are in working together internally, and then as we are defining where the value is, deciding whether the focus is on strengthening our relationships between our own disciplines, and/or  shaping our relationships with the external community.
The latter is truly the focus of our work, but what we like to say is that we practice collaboration internally in order to learn best how to foster collaboration externally.

Beautiful.


The external community, because it lumped all our disciplines together as CAM, created this fiction, a classic granfalloon.

For our readers who may not recognize that reference, it’s from the great 20th century American novelist, Kurt Vonnegut. “Granfalloon” is Vonnegut’s word for a group identification that seems unifying on the surface, but when you dig deeper, as Gertrude Stein famously said, “there’s no
there there.”

Exactly. Anybody inside these fields knows that there have been legislative battles when these fields fight against each other and work to restrain each other’s practice growth and/or licensing. And so it’s not necessarily one happy family. There was real bridge-building work required and I truly credit Pamela Snider, ACCAHC’s co-founder and first executive director, for the patience and the hand-holding to get everybody into the room in the first place.

To this day, there’s a subset of people from each of these disciplines who see the value in this level of collaboration, and there are subsets in each of the disciplines that really wonder what the heck their discipline is doing formally associating with and spending time or energy with the other fields. It was not, “Great idea, here we come!” If it had been, we would have seen this kind of collaboration emerge formally in the mid-1980s.

External Events Catalyze Internal Actions


We’re in an era now where there is a substantial push, particularly from the health policy side of the government sector, but also from the private sector, to push the different disciplines to collaborate, cajoling where they can and using force where they feel they must. In word and sometimes in deed, the goal is to benefit patients. What you’re describing within ACCAHC’s internal process and also in its external outreach, is a model worth emulating in terms of practicing the principles that we profess with regard to cross-disciplinary collaboration.


Absolutely. Let me give you an example. There was a great deal of press attention in May 2010 when the educators from the “Big 6” disciplines—medicine, nursing, public health, pharmacy, osteopathy and dentistry—came together and announced that they had been in a historic collaborative process over a year and a half to declare a set of Core Competencies for Interprofessional Collaborative Practice.

Since then, they have set up an organization to move interprofessional education. When we in ACCAHC learned about this, we found it interesting that a little before they began their process, we had decided internally that one of the most important areas where all of our disciplines have a shared challenge, and therefore a classic place for ACCAHC to go to work, was that all of us by and large educate our people in pure silos, institutions that sit by themselves. There are a few multidisciplinary universities and schools now, but by and large, the CAM model has been to set up a school and then educate people to go out and hang up a shingle and practice by themselves or with a few colleagues from their own fields. For the ACCAHC disciplines, we’ve been in pure silos, not just metaphorical ones.

So we had engaged a process to develop what we eventually called Competencies for Optimal Practice in Integrated Environments. Five disciplines plus the emerging professions worked through an elaborate process over the course of a year starting in September 2009, after a planning meeting where we got together for the first time with all of our working groups at Northwestern Health Sciences University. We realized that our highest priority was to help our people—our graduates, our students and our educators—to develop these competencies for optimal practice in an integrative environment. We are not talking about places where somebody is forcing you into a smaller scope or a smaller form of service than is appropriate, but about advocating for and being competent to work optimally in truly integrative environments. We declared this an ACCAHC priority. Then our educators did what educators do and said well, if we are going to move in this direction we need to define these competencies.

So we got involved with this process, worked with no discipline in charge, and ran our own competencies process roughly parallel with that of the Big 6. ACCAHC, having formed itself in 2004 with the same principle of shared leadership and collaborative leadership, is frankly quite ahead of the game. We started talking about the challenges in this integration without even realizing that we were talking about something that the mainstream was calling interprofessional education. That movement hadn’t really taken hold yet, as such.

Economic Influences on Interdisciplinary Collaboration

It’s still only in the formative stages.


And shame on U.S. healthcare for that. For some background, IOM published a report in 1972, at the same time that the movement to develop community health centers was taking shape. The group of people who worked on that IOM report was thinking much like people do in single-payer nations—seeing teams and collaboration as being critically important. Their focus at that time was principally in the outpatient environment. It didn’t take off.

Why didn’t it take off?


It’s generally accepted that the business model of U.S. medicine is misaligned with collaboration. In this longstanding model, people are being paid for the individual procedures they provide and are thus incented to do more themselves.

The old problem of volume versus quality.


Yes, it’s really about “how do you get paid?” There’s a great line from Atul Gawande’s famous work from 2009 that influenced the Obama Administration’s thinking. He was interviewing someone at the Mayo Clinic, who said, “If you want to foster collaboration and teamwork, the best way to do that is to have salaried employees.”

Mayo, of course, is probably the best known private sector example of that model in the United States.


Once you’re salaried, you are not thinking about how you’re going to make your buck. You’re now working in a context that is much more aligned with working with others. So here in the U.S., we’ve kept on doing what we do, in a way that is exceptional—and by that I mean unusual rather than good—amongst developed nations. Unfortunately, it’s just gotten worse and worse. This pattern has continued even after the IOM’s landmark report, To Err is Human, reported in 2000 that over 100,000 deaths a year are linked to mistakes in conventional medicine. And that number can go up to 250,000 depending on whose analysis it is. Medical errors are considered the fourth largest killer in the U.S.

So even after that important IOM report was released, and the IOM’s Crossing the Quality Chasm was published a year later, identifying the lack of respect and the divisions between different types of providers, the lack of communication, the historic antagonisms between disciplines (particularly between doctors and nurses) as a core factor in medical errors, we still didn’t really see this movement take off. Morbidity and mortality alone were not enough to shift us out of our economic ways into team care and the interprofessional education that would support it.

So did a tipping point arrive when the economic trend lines eventually reached the point where virtually everyone could see that doing what we were doing was rapidly becoming financially unsustainable?


What happened was that the Affordable Care Act (ACA) was passed and started promoting accountable care organizations, along with the patient centered medical home, another movement that predated ACA. Many of the principles in the ACA were already in play before it got that push from the federal government. Now, as Ken Paulus, the CEO of the Allina system in Minnesota, said last November at a symposium in New York, “For the first time in a hundred years, we here at Allina can get paid to keep the village healthy.” Accountable care organizations offer financial incentives for collaboration and team care.

By having these incentives, hospitals are recognizing that you need to be thinking much more about your hand-offs, about how you’re working with teams. About how once you’ve completed a surgery, you don’t just discharge someone, but instead you transition them and try to work with them so that they don’t need to come back into the hospital again, because now you’re incented to keep them out of the hospital. You’ll get better Medicare payments if fewer patients return.

This is one of many major reforms currently being implemented by Medicare. It saves the system money and it’s also better for people’s health.


Collaboration Across Borders


My view is that it took the economic inventive, really, to finally move the system toward collaboration. We in ACCAHC saw the scale of this change reflected at the Collaboration Across Borders conference in Arizona in 2011, which we attended on behalf of integrative practice. This is the big IPE meeting, and it had roughly double the attendance of the previous meeting two years before. Remember, it was in 2010 that the IPE/C [interprofessional education and care] group of the Big 6 declared its competencies, which catalyzed a great deal of additional interest in this area. I mean, they could have read Crossing the Quality Chasm ten years earlier and said, “My God, we’re killing people so let’s start working together.” But they didn’t. The deaths were not sufficient.

We in ACCAHC have come to realize that the whole IPE movement presents us with a very important opening to create relationships where there were none.
There is now an ethical basis around patient-centered care which the interprofessional education movement says is at its core. So we recognize that this activity is going on in conventional medicine, and that if they’re calling what they’re doing “patient-centered,” and if somewhere between 40 and 60 percent of people with chronic conditions are exploring alternatives, then having the providers at the table who are most expert in those alternatives is the most patient-centered choice. To exclude them is a provider-centered choice.

Which underscores the importance of having a CAM presence at a conference like Collaboration Across Borders.


It’s why we were in Tucson. Thanks to our donor, Lucy Gonda, we were able to be co-sponsors and to give out copies of our Clinicians’ and Educators’ Desk Reference on the Licensed Complementary and Alternative Healthcare Professions to each of those educators who had self-identified as interested in IPE. We see them as the conventional academic community that, second only to the integrative medicine academics, is most likely to be open to us. Therefore, one of our ACCAHC initiatives is to be engaged in that movement.

We are already talking with the Canadian Interprofessional Health Collaborative, which will be sponsoring the next Collaboration Across Borders meeting in 2013. We’re discussing ways to partner with them; we’ve already created a presence for our fields on their blogs and website. This is a group that is funded by Health Canada [the Canadian single payer system]. It is a prime mover of IPE in Canada and has also helped to nurse along the IPE movement here in the U.S., which started to take off here a decade later than in Canada.

In that context, I was at the press conference in May when the Big 6 rolled out their competencies. While there, I met an IOM staffer. A principle for us at ACCAHC is that, if there are significant health care discussions going on and the licensed disciplines and integrative principles we represent are not at the table, then chances are that the public’s interest in whole-person health care, and integrative practitioners and practices, and health-focused ways of educating people and delivering care are quite likely to not be inside of those dialogues. So when there are big conversations and we learn about them, we so everything we can to come up with the wherewithal and the right people to take part.
 
Representing CAM at National and International Forums

I want to ask about ACCAHC’s involvement in two current projects, the
Institute of Medicine’s Global Forum on Innovation in Health Professional Education and the Pain Action Alliance to Implement a National Strategy.
These are two of our big projects right now. Let me address the Pain Action Alliance first. This came from two directions. We learned that the IOM was going to set up a committee to develop a national blueprint on pain. The board of ACCAHC charged me to call IOM and point out that millions of people are utilizing massage therapists, chiropractors, acupuncturists, yoga therapists, and, for GI issues, naturopathic doctors for pain-related conditions. So somebody from these disciplines should be at this table. We make it kind of easy for them, because we can bring all of the disciplines to the table at once.

Is that how Rick Marinelli became a member of the IOM pain task force?


Yes. To give you a little more background, this is the second time we’ve helped make it possible for CAM practitioners to take part in Institute of Medicine events. A few years ago, the Bravewell Collaborative funded an IOM initiative to have a Summit on Integrative Medicine and the Health of the Nation. They began that with no intention of having anybody from the licensed CAM disciplines on the planning committee.

How very revealing.


Their bias is that if anything is run by an MD, it’s okay. And if it’s not, it’s minor, a mere modality. The view tends to be that CAM practitioners are simply not people who are capable of being in leadership or at least not useful in leadership of the movement in integrative medicine that they are promoting. So in 2008, in advance of the IOM Summit, we reached an IOM staffer and explained that we’ve got five disciplines that are recognized by the federal government that have integrative philosophies that appreciate that the mind and body are each involved in health and disease. We educated them to the fact that some 350,000 licensed practitioners from these disciplines are out there treating people. The staffer said, you’re right, please give us some names. And they chose our chair, Liza Goldblatt [Elizabeth Goldblatt, PhD, MHA, is Vice President for Academic Affairs at the American College of Traditional Chinese Medicine and Past President of the Council of Colleges of Acupuncture & Oriental Medicine].

The same kind of thing happened with the pain task force. Once again we found the IOM staff to be exceptional, balanced, scholar-policy people. They see the picture outside of the guild lens and they truly practice something that feels like it’s patient-centered. So they asked for some names and we gave them five names, of which the top two were a chiropractor with a Master’s in Public Health and a naturopathic doctor who is an acupuncturist. They chose Rick Marinelli, the ND and licensed acupuncturist, who was a prior president of the American Academy of Pain Management.

Pain Action Alliance to Implement a National Strategy (PAINS)


The difference between having one person at the table and have no one at the table is immeasurable.
 

No question. So we’ve been involved in that process, as was Myra Christopher, who was also selected for that IOM committee on pain. Myra heads the Center for Practical Bioethics in Kansas City. Interestingly enough, before the IOM process, Myra had contacted Rick Marinelli and told him that they would be doing a regional meeting in the Pacific Northwest toward developing a national pain strategy. She asked him to participate. Rick referred her to me and ACCAHC, in part because the meeting was going to be in Seattle, where I live.

I helped organize a small turnout of people for that meeting and then we, through ACCAHC, helped organize a few other people to show up at their other regional meetings. That led to Vince DeBono, a chiropractor and VP at National University of Health Sciences, participating in their national strategy session and becoming what we call the external affairs representative from ACCAHC to what is now a formal national pain strategy, managed through the Center for Practical Bioethics. We will have three representatives on committees of the Pain Action Alliance to Implement a National Strategy. As you know, you’re going to be one of them. Another is Martha Menard, a massage therapy researcher who is on our Research Working Group. We’re also planning to include an acupuncturist.

Pain management is increasingly accepted as an integrative and multidisciplinary process. That’s what the IOM report recommended and what Myra and the Center for Practical Bioethics have been promoting, which is evidenced by her reaching out to Rick originally in her regional meetings, and by her strongly welcoming ACCAHC’s involvement through the whole process. We are now a founding sponsor of this new initiative.

ACCAHC is the only CAM-oriented group at this table.
Among the other groups are the Federation of State Medical Boards, American Osteopathic Association, American Pain Society, and other representatives of the medical profession and in some instances, the pharmaceutical industry. Again, if even one of us is in the room, it has the potential to influence the nature of the discussion.

Institute of Medicine Summit on Integrative Medicine


We know that by getting Liza Goldblatt involved on the IOM Summit on Integrative Medicine planning committee, she strongly advocated that all of the papers that were to be contracted should be done by multidisciplinary groups rather than one MD or one academic medicine person.

I’ve read those papers and they did include authors who were chiropractors, acupuncturists and naturopaths.


At the IOM Summit itself, Liza and a licensed massage therapist researcher, Janet Kahn, were both plenary speakers. We also had people co-authoring papers and participating in break-out sessions. So yes, the human reality is that if you go into a room and you look around the table and you see your old clan, then you think about how your old clan can move things. But if you look around the table and see that there’s a new tribe, or new tribes, here at the table with us, the table is in fact larger and so you need to be more inclusive. There will be moments that will come up where that person who is there, who bears that responsibility, can make a tremendous difference. In the IOM pain report, Relieving Pain in America, the fact that Rick was there is the reason there’s language in the IOM pain blueprint that specifically calls out the value of our disciplines.

I quote that language in some of the classes that I teach. It speaks powerfully to the way that CAM practitioners have certain strengths that conventional medical practitioners lack.


“CAM holds special appeal for many people with pain for several reasons: deficits in the way that many physicians treat pain, using only single modalities without attempting to track their effectiveness for a particular person over time or to coordinate diverse approaches … and a welcoming, less reserved attitude toward people with pain on the part of CAM practitioners and an apparent willingness to listen to the story of a patient's pain journey." (Institute of Medicine, 2011)

So when somebody reads through the document, there you are. There’s language around the licensed CAM disciplines. Somebody else might have brought that up, but our perspective is that if the distinctly licensed CAM disciplines are not explicitly included, they will frequently be excluded. As much as many of us do not like to be boxed as CAM, the fact is that right now, if NCCAM’s name was changed from the National Center for Complementary and Alternative Medicine to the National Center for Integrative Medicine, there are a lot of people who would say, oh, that’s just doctors working with psychologists and nurses.

Or rheumatologists working with primary care medical physicians and radiologists.


Exactly. Even in the area of pain, if you say we are engaging in integrative practice, and that’s the model that we’re recommending, for many people that will mean working better with our PTs and our psychologists and our social workers. Of course, those are steps in the right direction. But the team is less likely to include some of these CAM disciplines unless they are explicitly mentioned in the document. Once they are explicitly in the document, people who are pursuing grants, developing policy, making changes in their local communities, or opening the doors between themselves and conventional practices anywhere in the nation, can cite the IOM study that essentially says, “You’re in the game.”

Quite often, conventional medicine people pay attention to what the IOM includes and what it doesn’t. In any given case, one never knows. I view these like pebbles dropped in lakes. Placing our people on these committees and in these action plans can make a huge difference.

NIH Grants Help Drive Interdisciplinary Cooperation

One of the other offshoots of the IOM report on pain is that the National Institutes of Health in late 2011 put out a request for proposals (RFP) to create ten Centers of Excellence in Pain Education that they’re going to fund. Here in the Kansas City area, Myra Christopher from the Center for Practical Bioethics organized a consortium of educators from all of the training institutions for medicine, osteopathy, nursing, pharmacy, dentistry, physical therapy, occupational therapy and chiropractic. We’re currently waiting to see whether our application is approved.


One of 11 topics applicants could choose to focus on is Complementary and Integrative Pain Management. That’s the one our group chose. Interestingly enough, it was not me but rather one of the medical school representatives on the leadership team who was the key advocate for that choice. That was a wonderful surprise. Specifically mentioned among the subtopics for this category were spinal manipulation and massage, as well as a number of mind-body approaches including yoga, tai chi, qigong, mindfulness meditation and relaxation response. It’s quite something to see this embedded in an RFP from NIH. Whether or not we’re ultimately funded, this has already helped us forge collaborative relationships that did not exist previously. One small but promising offshoot is that a couple of weeks ago, I was on a panel at the University of Missouri Kansas City School of Pharmacy, talking to 150 students about approaches to chronic pain.


In the past decade, NIH funded a set of R25 grants to medical schools that required these conventional academic health centers to form relationships with so-called CAM institutions to foster education. That initiative, very unusual for NIH, had a profound impact in opening up truly patient-centered explorations. This NCCAM program broke down many barriers and demonstrated a broadened range of possibilities.

And, as in the case you noted, relationships were created for the first time in many communities simply by the act of collaborating on a grant proposal, regardless of whether it was funded. In fact, the main academic health people who were involved in getting the interdisciplinary National Health Education Dialogue together were people who had been funded through that R25 mechanism. So the NIH really deserves credit for helping to stimulate this whole interprofessional education dialogue, one of the outcomes of which was the creation of ACCAHC.

IOM Global Forum on Innovation in Health Professional Education


Let me return to your question about the Institute of Medicine’s Global Forum on Innovation in Health Professional Education. Once again, I was charged by the ACCAHC board to contact the IOM. I had an hour-long conversation with Patrick Kelley, the medical doctor and public health professional who was organizing the project. In this conversation, he was able to learn about ACCAHC, our work in the area of interprofessional education and our strategic projects for bettering health care. He also explained to me in depth how this forum was conceived to follow up on two significant studies that were published in the centennial year of the 1910 Flexner Report—the Lancet Commission Report and the Robert Wood Johnson Foundation Institute of Medicine report on the future of nursing.

The Global Forums are meant to take those “50,000 foot recommendations” and bring them closer to the ground and into practice. At the end of the call, he said, “If you all would be at the table, it would be a great addition to our dialogue.” So IOM was extremely helpful in bringing us to the table for this 3-year project.

I should add that this is a pay-to-play deal. All of the participating organizations have to ante up money and pay their own way to the meetings as well as staffing the work of planning two two-day IOM meetings on innovation-related topics that will convene in each of the 3 years. This is a significant commitment for ACCAHC, amounting to roughly $65,000 over the three years. Happily, we have just had a foundation notify us that they will cover $30,000. We’re still looking for the rest. We’re using internal resources while we seek the remainder of the funding.

“The Most Diverse Gathering Ever Convened by IOM”


I can see why you felt it was too good an opportunity to pass up.


Our board felt strongly about it. We are one of 32 organizations that are seated around this IOM table. This includes the AMA, the American Association of Medical Colleges [AAMC] and each of the national academic organizations from the Big 6 who collaborated to develop their competencies document. Those educational groups were the first ones brought to the table. The forum is also financially backed by the Josiah Macy Jr. Foundation, which has been backing the IPE movement in many ways.

It’s very exciting. I was able to be at the table for the first meeting. I’m ACCAHC’s alternate representative but Liza Goldblatt, our appointee again, couldn’t make the first meeting in early March 2012 so I had the pleasure of being a core participant. Again, there we were at a more expanded table. The co-chair, Jordan Cohen [President Emeritus of the AAMC] said, “I think this is the most diverse gathering of people that the IOM has ever convened for a committee.”

We found that many of the themes under consideration for the six two-day sessions we’ll be creating over the next 3 years are fascinating for all of our ACCAHC educators. The process is asking us to step up, which is a challenge because our institutions typically do not have the governmental support, the foundation support, or institutional infrastructure comparable to conventional medical institutions, so it’s harder for us to participate either in dialogues like these or some of the innovative interprofessional and international projects in health professional education that are being discussed.

Yet you are stepping up.


Part of the business model with ACCAHC is that we hope to attract philanthropic investment as a collaborative group and thus bring our disciplines to various tables when our individual disciplines can’t afford to be there. The recent grant of $30,000 was pleasing evidence that our business model might work!

Global Role of Traditional and Low-Tech Health Care


Because it’s a global forum in which we’re now participating, we’re in a particularly interesting place when we think about enhancing health care in populations across the globe. The current estimate by the World Health Organization is that something like 60 percent of the people in the world still get most of their primary care through traditional medicine or indigenous practice. These are manual therapies and herbal therapies and various things that communities themselves can provide.

The parallel for the non-indigenous in the United States are the natural health and complementary health and self-care practices utilized by many people that are typically outside of formal healthcare delivery. And again, many people in our disciplines have some expertise in those areas of traditional medicine, and they’re likely to be openly sympathetic by the nature of their own natural health care focus. The forum is not only a totally exciting place to be, it’s a place where we need to be. We carry some understanding that no one else at the table does.

Marking the Flexner Report Centennial, Exploring Possible Next Steps


For students of history, there’s an additional galvanizing component to it. As I mentioned, we’re now just past the 100-year anniversary of the Flexner Report. Most everybody in alternative medicine looks at the Flexner Report as a major negative moment in U.S. medical history.

In terms of it being a landmark moment in marginalizing alternatives to allopathic medicine, definitely. 


It was a power grab by the MDs and their medical schools that led to the shutting down of other programs. Power was aggregated inside of academic health systems, inside of tertiary care, and inside an overly scientized and eventually, technological, form of medicine in which, according to a February 2008 opinion piece in JAMA, half of what’s going on is waste and much of that is harmful.

But there are others aspects to Flexner. I believe that there are some strong, positive values in what Flexner advocated, with which ACCAHC is aligned. In particular, Flexner marked a watershed moment in emphasizing the importance of paying attention to evidence and investing in research …

To upgrade standards.


… and to ensure that as much as possible, we’re educating practitioners, and students who become practitioners, who are cognizant of the value of looking at the outcomes of what they’re doing. These were the positive aspects of what Flexner was bringing forward.

The moment of this IOM Global Forum is literally based on the two reports I mentioned earlier, that coincided with the centennial of the Flexner report of 1910. One of them was the Lancet Commission Report. The second was the incredibly powerful Robert Wood Johnson Foundation Institute of Medicine report on the future of nursing, which in many respects was a declaration of independence for the nation’s advanced practice nurses. Basically, the IOM said that the evidence is on the side of allowing advanced practice nurses to have autonomy in what they do, and that there are not legitimate safety issues that should prevent this.

The conclusion was that the “safety issues” raised by medical doctors about primary care nurses and nurse anesthetists practicing independently are effectively guild-related, not about actual practice. Everybody who is in the chiropractic field and the naturopathic field knows well that many times the same kinds of charges are leveled against them. Essentially, “It’s unsafe! You can’t be on your own! It’s irresponsible! You need to have Father Medicine overseeing what you’re doing!” Well, the Robert Wood Johnson IOM report basically said, “Sorry, medicine, you’re not in charge of the future of health care. You need to be sharing that turf.”

It’s clearly a major step to have IOM reports that call for interprofessional collaboration and an end to medical hegemony. That said, it’s far easier to have this included in an IOM report than to implement it as national policy. But above all, it may be an important signpost on the road that eventually takes us there.


Yes, and you can see the overlap of themes with interprofessional education here. The recommendations in these two reports track very well with the collaboration among the Big 6 that led to the development of the core competencies in that IPE/C group. One has more reason to collaborate if one is no longer solely in charge.

Think Globally, Act Globally


In addition, there’s a dual ground to this IOM Global Forum in that we’re looking not only at innovation such as IPE here in North America, but also at innovation to meet the changing scene internationally.

In so many ways, health care today is international. Something like 25% of the doctors working in U.S. hospitals are trained abroad. Many of us don’t know it, but we are getting our imaging done in shops in Bangalore and elsewhere. Many from North America go abroad for medical services and dentistry—the so-called medical tourism movement. There are entire health professions education factories, essentially, that have been built abroad and are turning out nurses and medical doctors in other nations to export those people to the United States, to put it in frank, product-like terms. So while we may say healthcare is local, we are very much an international community. That’s also part of what the IOM Global Forum is about.

Bringing Wellness Orientation to the Global Forum


Last January, the ACCAHC board discussed some of the proposed themes for the two-day forums, to identify ACCAHC’s highest priorities and essentially to give Liza Goldblatt and me our marching orders for the March 7-8 meeting. We examined a dozen of these theme areas that the IOM staff had proposed.

At one point, someone said, “I don’t see anything here on educating health care professionals towards a wellness orientation, towards empowering people and communities to be and stay healthy, to promote and create health.” The rest of the board quickly agreed that this is a theme that ACCAHC needs to propose and advocate for exploration. As we look ahead into this new century, the century after the Flexner centennial, might this not become the most important breakthrough direction for health professional education?

I was able to represent this theme at the March meeting and in subsequent email discussions. Happily, I can report that we have been getting some good feedback from the Forum leadership. We are not alone; there are others who affirm that they feel it’s a great theme to have on the table.

It’s a theme that is by no means limited to CAM. It should be something that everyone can enthusiastically support.


It is not about CAM at all, though it happens to be a place where all of our disciplines have a similar philosophy, even if we don’t always practice it. We sometimes practice in a disease model and just respond to the presenting conditions with a quick adjustment or a set of needles. But philosophically, all of our disciplines claim to be interested in being health-focused, and to be engaged deeply in teaching and trying to empower the people who seek our care.

I think, honestly, that if ACCAHC does its work well, we can provide some leadership in re-engaging all of our fields more deeply in that conceptual framework. The better we practice what we’d like to see, the more we will be capable of providing leadership in health care. At any rate, we are putting that concept out there, urging this direction as a legacy for this IOM initiative.

Aiming High


I believe this actually has the potential to attain something approaching a Flexnerian weight and dimension, so that in the future, people can look back and say that starting in 2012, this group set a course to train health professionals not merely to react in the moment, or to suppress the symptoms of diseases, but to realize that their job description needs to be much more expansive.

How can we train health professionals to see that their highest and best use is to empower people to not need their services? If this means taking on the payment system, well, who says that shouldn’t be the job of those who are getting paid? The Flexnerian revolution in medicine, directly and indirectly, led us to the tertiary care cathedrals that are draining the lifeblood of our economy and failing terribly to create health in individuals and populations.

The challenge before us is to create academic health programs that train people to drive care back out into communities, and, where possible, back into people’s homes and families in the form of self-care and self-efficacy. If we together can rise to that call, we could actually achieve the same level of revolution that Flexner’s report created 100 years ago. It’s the high ground on which our ACCAHC disciplines stand. And, of course, it would have significant implications for education inside and outside our own fields.

A previous version of this article was published in Health Insights Today, a publication of Cleveland Chiropractic College-Kansas City, and is reprinted with permission.

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