The interest in the government health care systems of the military and the sprawling Veteran’s Administration (VA) led to the most remarkable leadership of the Integrative Medicine professionals in shaping US medicine. The founding director in 2011 of the VA Office of Patient Centered Care and Cultural Transformation, Tracy Gaudet, MD, and her successor in that position in 2019, Ben Kligler, MD, MPH, were each long-time leaders of the Integrative Medicine movement. Gaudet had directed programs at what is not the University of Arizona Andrew Weil Center for Integrative Medicine and Duke Medical School for 15 years. Kligler’s experience included chairing the Consortium and directing data-gathering in a Bravewell-funded network of integrative academic medicine clinical programs.
Together, these two and their team envisioned and built the VA’s Whole Health program that featured expansive use of integrative services including chiropractic, acupuncture, massage, Mind Body Medicine, yoga therapy, tai chi and others. The program, which conceptually placed the veteran and his or her family at the center of care (Weeks 2018b), was piloted and thoroughly researched in 17 of the VA’s medical centers. A broad array of positive outcomes (Bokhour et al. 2020) led the VA, three years later, to expand the program to 55 medical centers. Notably, this action was taken in the context not of the competitive, volume-based industry but in the single payer VA system. There, like in the United Kingdom, practitioners were employed. In the VA hierarchy, they could also be required to learn about integrative practices and practitioners. These cultural-economic traits of the VA operation supported the most intensive integrative environments in the US.
Yet in the world of civilian medicine, convergence was also evident. Other forms of integrative activity also accelerated. Research related to complementary practice and practitioners funded by the military and by the NIH created a body of evidence that, with policy nudging, began to shift the chronic pain dialogue. Members of the Consortium, as noted above, convinced a key accrediting body to engage a review process that casting a spotlight on the value of non-pharmacologic approaches such as acupuncture, massage, chiropractic and mind body approaches in pain treatment (Division of Healthcare Improvement 2018). Within a half-decade, the American College of Physicians (Qaseem et al. 2017), and the National Academy of Medicine (Bain et al. 2019) were among the organizations and agencies that had either issued guidelines or guidance documents that stressed the importance of integrating these non-pharmacologic, integrative approaches.
3.3 Conclusion
This chapter has described how on a popular movement for an alternative to the dominant brand of medicine became known as “integrative health and medicine” and began to penetrated into and shift the kind of medicine people would find in the nation’s mainstream delivery organizations. Importantly, the majority of services of integrative medical doctors, of naturopathic physicians, chiropractors, acupuncturists, yoga therapists and others used by people in the US continue to be directly accessed in communities, outside of the dominant payment and delivery system. They remain “alternatives,” chosen by patients for their care and by practitioners because they believe them to have greater value in health and medicine than the mainstream of US medicine accords them. The integration of these services is thus typically engaged by each individual, often with an integrative practitioner’s guidance, and coordinated to greater and lesser extent with conventionally practicing physicians. Communication with conventional practitioners about such services remains low.
It is a paradoxical truism that, while the movement has come a long way, at the same time it has only just begun. In mid-2020, a new initiative was announced that grew out of this activity and is expected to leverage change toward integrative models more rapidly. The wealthiest woman in the world, Alice Walton, partnered with the former Veterans Administration “whole health” leader, Tracy Gaudet, MD, to found the Whole Health Institute. The announce plan was, among other things, to take from the knowledge and models developed inside the VA and spread them through civilian health and medicine. To lead change in hospitals and medical delivery organizations, Gaudet brought in Lori Knutson, RN, BC-HN, the professional known to have the most experience in the US in successfully building integrative and wellbeing programs in major medical delivery organization.
While a full plan is only emerging, a sense of its scope can be seen not only in Knutson’s hiring but also in two announced initiatives (Weeks 2020b). One is partnership with Whole Health ED, an organization targeting placement of integrative health-oriented programs in K-12 education. Among these: mind body programs, experiences in nature, creative arts therapies, healthy eating, school vegetable gardens, and more. The other is a plan to create a new medical school to be shaped around fostering whole health values and principles. Walton has shared interest in influencing health and medicine via Whole Health Institute initiatives throughout the US, and globally. The possibilities are grand when a yet unannounced portion of Walton’s $ 54-billion net worth will be committed. The transformational ideas of the Sixties, carried by consumers and organizers of a grassroots movement, appear to have expansive opportunities for continuing convergence, and leadership, ahead.
References
Bain L, Posey SM, Stroud C (2019) The Role of Nonpharmacological Approaches to Pain Management: Proceedings of a Workshop. Forum on Neuroscience and Nervous System Disorders and Global Forum on Innovation in Health Professional Education. Health and Medicine Division, National Academies of Sciences. Accessed online August 27, 2020 at URL: https://www.nap.edu/read/25406/chapter/1
Boat TF, Chao SM, O’Neill PH (2008) From Waste to Value in Health Care. Commentary, February 6, 2008. JAMA Feb 6; 299(5):568–571. DOI: https://doi.org/10.1001/jama.299.5.568
Bodenheimer T, Sinsky C (2014) From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider. Ann Fam Med 12(6):573–576. DOI: https://doi.org/10.1370/afm.1713
Bokhour BG, Hyde J, Zeliadt S et al. (2020) Whole Health System of Care Evaluation – A Progress Report on Outcomes of the WHS Pilot at 18 Flagship Sites. Center for Evaluating Patient-Centered Care in the VA. USA Veteran’s Health Administration. Accessed online August 27, 2020 at URL: https://www.va.gov/WHOLEHEALTH/docs/EPCCWholeHealthSystemofCareEvaluation-2020-02-18FINAL_508.pdf
Clugston R, Goldblatt E, Rosenthal B et al. (2017) Clinicians and Educators Desk Reference on the Licensed Integrative Health and Medicine Professions, 3rd Edition, 2017. Academic Collaborative for Integrative Health. Accessed August 27, 2020 at URL: https://integrativehealth.org/desk-reference-integrative-health-professions
Division of Healthcare Improvement (2018) Non-pharmacologic and non-opioid solutions for pain management. Quick Safety 44. Joint Commission. Accessed August 27, 2020 at URL: https://www.jointcommission.org/-/media/tjc/documents/resources/pain-management/qs_nonopioid_pain_mgmt_8_15_18_final1.pdf
Eisenberg DE, Kessler RC, Foster C et al. (1993) Unconventional Medicine in the United States – Prevalence, Costs, and Patterns of Use. January 28, 1993. N Engl J Med 328:246–252. DOI: https://doi.org/10.1056/NEJM199301283280406
Herman P, Poindexter B, Witt C, Eisenberg D (2012) Are Complementary therapies and integrative care cost-effective? A systematic review of economic evaluations. BMJ Open, Health Economics. Accessed online August 27, 2020 at URL: https://bmjopen.bmj.com/content/2/5/e001046
IHI Leadership Alliance (n.y.). New Rules for Radical Resign of Healthcare. The Institute for Healthcare