Summary

On February 25–27, 2009, the Institute of Medicine (IOM) convened the Summit on Integrative Medicine and the Health of the Public in Washington, DC. The summit brought together more than 600 scientists, academic leaders, policy experts, health practitioners, advocates, and other participants from many disciplines to examine the practice of integrative medicine, its scientific basis, and its potential for improving health. This publication summarizes the background, presentations, and discussions that occurred during the summit.

INTRODUCTION

The last century witnessed dramatic changes in the practice of health care, and coming decades promise advances that were not imaginable even in the relatively recent past. Science and technology continue to offer new insights into disease pathways and treatments, as well as mechanisms of protecting health and preventing disease. Genomics and proteomics are bringing personalized risk assessment, prevention, and treatment options within reach; health information technology is expediting the collection and analysis of large amounts of data that can lead to improved care; and many disciplines are contributing to a broadening understanding of the complex interplay among biology, environment, behavior, and socioeconomic factors that shape health and wellness.

Although medical advances have saved and improved the lives of millions, much of medicine and health care have primarily focused on addressing immediate events of disease and injury, generally neglecting underlying socioeconomic factors, including employment, education, and



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Summary On February 25–27, 2009, the Institute of Medicine (IOM) convened the Summit on Integrative Medicine and the Health of the Public in Washington, DC. The summit brought together more than 600 scientists, academic leaders, policy experts, health practitioners, advocates, and other participants from many disciplines to examine the practice of inte- grative medicine, its scientific basis, and its potential for improving health. This publication summarizes the background, presentations, and discussions that occurred during the summit. INTRODUCTION The last century witnessed dramatic changes in the practice of health care, and coming decades promise advances that were not imaginable even in the relatively recent past. Science and technology continue to offer new insights into disease pathways and treatments, as well as mechanisms of protecting health and preventing disease. Genomics and proteomics are bringing personalized risk assessment, prevention, and treatment options within reach; health information technology is expedit- ing the collection and analysis of large amounts of data that can lead to improved care; and many disciplines are contributing to a broadening understanding of the complex interplay among biology, environment, behavior, and socioeconomic factors that shape health and wellness. Although medical advances have saved and improved the lives of millions, much of medicine and health care have primarily focused on addressing immediate events of disease and injury, generally neglecting underlying socioeconomic factors, including employment, education, and 1

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2 INTEGRATIVE MEDICINE AND THE HEALTH OF THE PUBLIC income, and behavioral risk factors. These factors, and others, impact health status, accentuate disparities, and can lead to costly, preventable diseases (IOM, 2001b). Furthermore, the disease-driven approach to medicine and health care has resulted in a fragmented, specialized health system in which care is typically reactive and episodic, as well as often inefficient and impersonal (IOM, 2007b; Snyderman and Williams, 2003). In health terms, the consequences of this fragmentation can be seri- ous. Chronic conditions now represent the major challenge to the U.S. health care system. Five chronic conditions—diabetes, heart disease, asthma, high blood pressure, and depression—account for more than half of all U.S. health expenditures (Druss et al., 2001). Among Medicare recipients, 20 percent live with five or more chronic conditions and their care accounts for two-thirds of all Medicare expenditures (Anderson, 2005). Many of these conditions are preventable, but only about 55 per- cent of the most recommended clinical preventive services are actually delivered (McGlynn et al., 2003). Care coordination that emphasizes wellness and prevention, a hall- mark of integrative medicine, is a major and growing need for people both with and without chronic diseases. Those with chronic diseases rarely receive the full support they need to achieve maximum benefit. A patient’s course of care may require contact with clinicians and caregiv- ers and may require many transitions, for example from hospital to home care. However, these transitions often are poorly handled, leading to ad- verse events that result in rehospitalizations 20 percent of the time (Forster et al., 2003). The IOM report To Err is Human concluded that half of all adverse events are caused by preventable medical errors. In- deed, it estimated that medical errors are responsible for some 44,000 to 98,000 deaths per year, ranking errors among the nation’s leading causes of death (IOM, 1999). Disconnected and uncoordinated care amplifies the economic burden of the health care system. The costs of U.S. health care are driven in large part by the inefficiencies, redundancies, and excesses of the current fragmented system and are considered by many economists and policy makers to be unsustainable, either for individuals or for the nation. In 2009, nearly $2.5 trillion will be spent in the United States in a health care system that is underperforming on many dimensions. The current trend will drive expenditures to $4.3 trillion by 2017 (Keehan et al., 2008) unless changes are made. Despite per capita expenditures that are at least twice as high as the average for other Western nations, the United

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3 SUMMARY States ranks far down the global list in the health of its citizens (Schoen et al., 2006). Estimates by various experts suggest that one-third to one- half of U.S. health expenditures do little to improve health (U.S. Con- gress, 2004; U.S. Congress, 2006). Combined, economic challenges and dissatisfaction with the current system drive interest in health reforms that would offer lower-cost, more effective, holistic, evidence-based approaches. This interest is growing concurrent with, and fueled by, growth in the science base about the rela- tionships among health, the pace of healing, and more intangible ele- ments of the caring process, including empowerment of patients to play a central role in their care. Evidence is accumulating about the variety of factors that have important effects on health care outcomes: the interac- tion between an individual’s social, economic, psychological, and physi- cal environments, and his or her biological susceptibility to illness and responsiveness to treatment; the nature of the care process, as well as its content; and the often greater health benefit to be had from certain “lower tech” interventions, rather than more costly approaches. In addition, the interest in unconventional approaches to prevention and treatment has grown. In 2007, nearly two of every five Americans over the age of 18 reported use of therapies such as yoga, massage, medi- tation, and natural products and supplements (Barnes et al., 2008). In total, such approaches accounted for $34 billion in out-of-pocket expen- ditures in 2007 (Nahin et al., 2009). And, more than half of all Ameri- cans over the age of 18 report regular use of dietary supplements, supporting a $23 billion industry (National Institutes of Health, 2006). Some of these practices are based on the experience of cultures over time, some are based on evolving scientific theories, and some are based on little more than belief. Each compels an assessment of what is lacking in conventional health care that causes so many people to turn elsewhere for help. Stakeholders must determine which models and approaches to health care, conventional or otherwise, might best integrate the science, caring, efficiency, and results that patients desire and that improve opti- mal health and well-being throughout the life span. This is the background to the IOM’s Summit on Integrative Medi- cine and the Health of the Public. Integrative medicine may be described as orienting the health care process to create a seamless engagement by patients and caregivers of the full range of physical, psychological, so- cial, preventive, and therapeutic factors known to be effective and neces- sary for the achievement of optimal health throughout the life span. The aim of the meeting was to explore opportunities, challenges, and models

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4 INTEGRATIVE MEDICINE AND THE HEALTH OF THE PUBLIC for a more integrative approach to health and medicine. This approach could shift the focus of the health care system toward efficient, evidence- based practice, prevention, wellness, and patient-centered care, creating a more personalized, predictive, and participatory health care experience. THE SUMMIT ON INTEGRATIVE MEDICINE AND THE HEALTH OF THE PUBLIC The IOM Summit on Integrative Medicine and the Health of the Pub- lic was sponsored by the Bravewell Collaborative, and was planned by a 14-member committee, chaired by Dr. Ralph Snyderman. 1 The summit was designed to consider how integrative concepts can fit within a num- ber of initiatives for transforming the health care system, including pa- tient-centered care; personalized, predictive, preventive, participatory medicine; mind-body relationships; the expanding science base in ge- nomics, proteomics, and other fields; health care financing reform; shared decision making; value-driven health care; and team-based care processes. The agenda was divided into five half-day sessions, each with a key- note speaker, a panel of expert presenters, and audience discussion. The plenary sessions covered overarching visions for integrative medicine, models of care, workforce and education needs, and economic and policy implications. One of the planning committee’s goals was to afford abun- dant opportunity to hear from summit participants. Ample time was al- lowed for questions and answers during plenary sessions; luncheon discussion groups allowed participants to continue plenary discussions; and five small assessment groups discussed priorities in assigned topic areas and reported to the plenary on their discussions. SUMMIT THEMES The summit provided the opportunity for all attendees to hear from and provide a rich array of experiences, diverse perspectives, and a vari- ety of fresh ideas. Certain refrains were often repeated in different ways throughout the course of the summit (see Box S-1). 1 The role of the planning committee was limited to planning and preparation of the summit. This document was prepared by rapporteurs as a factual summary of what was presented and discussed at the summit.

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5 SUMMARY BOX S-1 Recurring Summit Perspectives on Integrative Medicine Vision of optimal health: alignment of individuals and their health care for optimal health and healing across a full life span Conceptually inclusive: seamless engagement of the full range of estab- lished health factors—physical, psychological, social, preventive, and therapeutic Lifespan horizon: integration across the lifespan to include personal, predictive, preventive, and participatory care Person-centered: integration around, and within, each person Prevention-oriented: prevention and disease minimization as the foun- dation of integrative health care Team-based: care as a team activity, with the patient as a central team member Care integration: seamless integration of the care processes, across caregivers and institutions Caring integration: person- and relationship-centered care Science integration: integration across scientific disciplines, and scien- tific processes that cross domains Integration of approach: integration across approaches to care—e.g., conventional, traditional, alternative, complementary—as the evidence supports Policy opportunities: emphasis on outcomes, elevation of patient in- sights, consideration of family and social factors, inclusion of team care and supportive follow-up, and contributions to the learning process These themes represent some of the characteristics and priorities cours- ing throughout summit presentations and participant discussions: Vision of optimal health. Integrative medicine, or integrative health care, seeks the alignment of individuals and their health care for optimal health and healing across the life span. Conceptually inclusive. Integrative health care means different things to different people, but common elements describe a care process in which patients and caregivers work together to foster seamless engagement of the full range of health factors— physical, psychological, social, preventive, and therapeutic— known to be effective and necessary to achieve optimal lifelong health. Lifespan horizon. The perspective of integrative health care ex- tends across the life span. Fundamental to its philosophy is the

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6 INTEGRATIVE MEDICINE AND THE HEALTH OF THE PUBLIC notion of starting as early as possible—even before birth—to plan and shape a person’s health future. It is personal, predictive, preventive, and participatory. Person-centered. The orientation of health care is integrated around, and within, each person. That is, care not only accounts for differences in individual conditions, needs, and circum- stances, but it also engages patients as partners in addressing the different biological, psychological, spiritual, and social and eco- nomic reference points that shape patients’ wellness, illness, and healing. The intensity of care and the support mobilized are tai- lored to the intensity of the person’s need and risk, as moderated by personal preferences. Prevention-oriented. With its focus on optimal health, preven- tion and disease minimization represent the foundation of inte- grative health care. The first priority for a health care system that uses an integrative approach is, therefore, to ensure that the full spectrum of prevention opportunities—clinical, behavioral, social, and environmental—are included in the care delivery process. Team-based. Integrative health care envisions a care process that is a team activity, with the patient as a central team mem- ber. This differs from prevailing patterns of care that are often compartmentalized, fragmented, and delayed. An integrated health team would employ professionals with a wide spectrum of expertise and skills and diverse, interdisciplinary education and training in a set of core competencies. Care integration. In integrative health care, the seamless inte- gration of the care processes, across caregivers and across insti- tutions, is the most fundamental organizational principle. Whether through the use of patient navigators or health coaches, whether through care support tools and electronic health records that support the patient focus, or whether through payment sys- tems pegged to patient outcomes, every aspect of system design should further the goal of integration. Caring integration. Person-centered care is also relationship- centered care. In integrative health care, care is integrated not only across organized caregiver sites, but across the relevant life dimensions—embracing and including home, family, loved ones, and the community. Care also considers the social and economic

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7 SUMMARY factors that affect health, including employment status, educa- tion, income, social networks, and family support. Science integration. Integrative health care is derived from les- sons integrated across scientific disciplines, and it requires sci- entific processes that cross domains. The most important influences on health, for individuals and society, are not the fac- tors at play within any single domain—genetics, behavior, social or economic circumstances, physical environment, health care— but the dynamics and synergies across domains. Research tends to examine these influences in isolation, which can distort inter- pretation of the results and hinder application of results. The most value will come from broader, systems-level approaches and redesign of research strategies and methodologies. Integration of approaches. Integrative health care is integrated across approaches to care—e.g., conventional, traditional, al- ternative, complementary—as the evidence supports. In addition to the best application of conventional allopathic approaches, it may use evidence-based interventions or practices derived from ancient folk practices, cultural-specific sources, contemporary product development, or crafted from a blend of these. Sound practice requires that the standards of evidence be appropriate to the modality assessed, consistent across the range of options, and structured to assess broad outcomes over time. Policy opportunities. Policies that encourage integrative health care would define value in terms that emphasize outcomes, ele- vate patient insights, account for family and social factors, en- courage team care, provide supportive follow-up, and contribute to the learning process. In addition to these recurring themes, participants offered a number of suggestions throughout the course of the presentations, discussions, and breakout sessions on ways in which the science, practice, application, and effectiveness of integrative health and medicine might be enhanced. Specific participant suggestions and proposals included those related to: Research, such as clarification of the nature and pathways by which biological predispositions and responses interact with so- cial and environmental influences, redesign of study protocols to better accommodate multifaceted and interacting factors, and

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8 INTEGRATIVE MEDICINE AND THE HEALTH OF THE PUBLIC demonstration projects to identify effective integrated ap- proaches that demonstrate value, sustainability, and scalability; Practice, such as team approaches that improve outcomes, tools that facilitate life span approaches to the care process, reorgani- zation of provider profiles at care entry points to improve patient engagement and support; Education, such as redefining core competencies, exploration of new care categories, and reorienting health professions training to emphasize prevention, well-being, and team approaches; and Policy, such as clarity on the standards of evidence that shape practice and payment, development of incentives that support the necessary developments in research, education, and practice, in particular those that encourage care coordination, team care, pa- tient engagement, and an orientation to prevention and well- being. A number of these suggestions are highlighted in greater detail in later sections of this summary as reflections of the discussion but not as consensus or recommendations, which was not the purpose of the summit nor the intent of this summary. SUMMIT IN BRIEF 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 medi- cine 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 possi- bility to fulfill the longstanding World Health Organization defi- nition of health as more than the absence of disease. It should include physical, mental, emotional, and spiritual factors, ena- bling a comprehensive understanding of what makes a person healthy.

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9 SUMMARY 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 coordi- nation 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 acknowl- edged that many of the ways to improve health must be actively pro- moted 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 ad- vances 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 trans- formation—one that again would be propelled by new advances in sci- ence, 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 par- ticipatory 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 cur- rent health care system is fragmented and not oriented to health promo- tion or disease prevention. Panel moderator, Dr. Michael Johns, for example, noted that much of today’s health care system focuses on treat- ing major, often fatal, diseases, but these efforts are not sufficient to

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10 INTEGRATIVE MEDICINE AND THE HEALTH OF THE PUBLIC achieve a healthy population. Bill Novelli described the large contribu- tion 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 ac- tion 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, includ- ing expansion of the pool of primary care providers suggested by Sier- pina 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 pa- tient-centered care. Ellen Stovall emphasized that clinicians must recog- nize that many of the skills patients need to actively participate in decision making about their care evaporate in the face of a serious ill- ness, 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 dis- ease 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 effec- tively 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

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11 SUMMARY 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 de- fine what is being integrated, why, and then ultimately to integrate itself. Drawing in part on his previous IOM committee work, Berwick pro- posed 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 ill- nesses of loneliness, depression, anger, and hostility are every bit as dev- astating 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 en- hanced information technology, and include structured patient involve-

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12 INTEGRATIVE MEDICINE AND THE HEALTH OF THE PUBLIC 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 effec- tively 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 ele- ments 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 out- comes patients should expect. Katz noted that patients often have con- cerns that are in a gray zone, and the only way to effectively address them is by understanding more about the individual context of their con- cerns. 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.

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13 SUMMARY 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 con- sumerism 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, espe- cially 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 sys- tems approach in both health care and in health sciences research that accounts for multiple variables interacting in dynamic ways. In his pres- entation, 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 adminis- tered separately, they act differently, which demonstrates that these fac- tors do not generally act independently but in complex interdependence with other dietary components. Ornish went on to note that various studies that examine the influ- ence of supportive relationships and comprehensive lifestyle change sug- gest 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 longev- ity) 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

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14 INTEGRATIVE MEDICINE AND THE HEALTH OF THE PUBLIC 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 expec- tancy, 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 ef- fective 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 exam- ples of diseases such as breast cancer, Alzheimer’s, hypercholes- terolemia, 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 ap- proaches 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 cumula- tive 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 sys- tems, 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, hor- mones 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-

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15 SUMMARY 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 ad- vances and the need for studies to accelerate progress. Yet many, includ- ing Dr. Lawrence Green who was charged with reviewing research challenges, noted the complexity of studying the involved factors. In par- ticular, this complexity presents a significant limitation to the use of ran- domized clinical trials, which test one variable at a time and are not designed to evaluate multifaceted preventive approaches, such as life- style interventions. New, more appropriate assessment methods are under development. They range from improved effectiveness trials at the com- munity 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 re- search, noting that approximately half of NCCAM’s resources are de- voted 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 de- scribed the implications of advances in integrative medicine for the edu- cation and training of the nation’s health professionals and researchers. They discussed strategies for changing curricula, including interdiscipli- nary approaches, team-based training, and expansion of core competen- cies 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

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16 INTEGRATIVE MEDICINE AND THE HEALTH OF THE PUBLIC take into account the social and economic determinants of health, which requires a very different set of provider profiles, competencies, and train- ing. 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 empha- sized, a rational approach to health care requires a team approach, in or- der 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 pa- tients desire collaboration among their health care providers, which pre- sumes 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. Interpro- fessional 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 ap- proaches, 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 dis- ruptive 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 practitio- ners 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 curricu- lum was the fact that, regardless of professional and specialty mix, health

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17 SUMMARY care practitioners today are not able to overcome some of the most im- portant 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, ap- proximately 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 im- plications 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 pa- tient safety the top priority. However, evaluation needs to go beyond this to address questions of benefit and cost-effectiveness. One of the chal- lenges is to ensure that the consideration of benefit includes individual patient values. In the matter of credentialing, Chantler noted that stan- dards 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 re- marks 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 pre- vention and wellness. Harkin noted that, unlike previous occasions, pub- lic 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- 2 Organisation for Economic and Co-operation and Development.

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18 INTEGRATIVE MEDICINE AND THE HEALTH OF THE PUBLIC 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 discus- sion 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 sup- ported development of community health teams that would include nurse practitioners, social workers, and behavioral health workers to collabo- rate with these practices to make these services available. Dr. Janet Kahn also suggested greater coordination of health- promoting activities across government agencies, including agencies out- side of the Department of Health and Human Services, as part of the re- form 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 advo- cates 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 evi- dence on workable models that could be used to support changes in fi- nancing. 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

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19 SUMMARY 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 corpo- rate 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 employ- ers 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, presen- teeism, and performance. Pelletier noted that the studies he reviewed re- flected 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 discus- sion, participants noted the clear emphasis throughout the summit on re- orientation of care to perspectives that emphasized prevention, were per- son centered and life span long, accommodated multidisciplinary team engagement, and tended to the social, home, and relationship environ- ments 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 pat- terns. Rather, in integrative health an entirely new orientation is needed, including the involvement of an “optimizer”—human and/or elec- tronic—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 incen- tives into alignment with the vision.

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20 INTEGRATIVE MEDICINE AND THE HEALTH OF THE PUBLIC 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 under- standing the range of factors in play for the whole patient, not just the physiologic correlates of the presenting symptom. She noted that if peo- ple are educated in silos, they will practice in silos, and that style of prac- tice 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 reso- nance with the values of integrative medicine—internal reflection, con- nectedness, 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 dis- cussions to point fingers and place blame across sectors. Finally, he pre- dicted 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 plan- ning 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 open- ing remarks, Snyderman reiterated that everyone had arrived at the meet- ing 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 un- derstanding, to identification of common elements, and to appreciation that at its center is an individual with unique requirements for maintain- ing 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

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21 SUMMARY children, with their different socioeconomic backgrounds and opportuni- ties, their different racial and ethnic identities, their different family dy- namics, 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 spon- taneous actions and the creativity of every person in the audience. We all can play a role in keeping this movement going forward.”

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